Every finding on record at Preferred Care at Wall

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to store food in accordance with professional standards for food service safety related to storage height and temperature monitoring. This deficient practice was evidenced by the following:1.) On 06/11/26 at 10:04 AM, the surveyor toured the kitchen with the Food Service Director (FSD). When touring the dry food storage area, boxed items were observed being stored less than 18 inches from the ceiling. The surveyor observed painted lines on the wall which indicated a measurement of 18 inches from the ceiling. During an interview at that time, the FSD stated that items in the dry food storage area should be kept more than 18 inches from the ceiling as a matter of fire safety in the kitchen. On 06/18/26 at 9:50 AM, during an interview the Licensed Nursing Home Administrator (LNHA) stated that items in the dry food storage area should be kept more than 18 inches from the ceiling to allow room for sprinklers to reach anything which would be affected in the event of a fire in the kitchen, as the spread of a fire would have been hazardous to residents. 2.) On 06/11/26 at 10:59 AM, the surveyor toured the C unit pantry. Both the fridge and freezer did not have an internal thermometer in place.During an interview at that time, the Regional Food Services Director (RFD) indicated that there should have been an internal thermometer present in both the fridge and freezer to prevent the potential spoilage of food. On 06/18/26 at 9:50 AM, during an interview the LNHA stated that there should have been an internal thermometer present in both the fridge and freezer to prevent the potential spoilage of food. 3.) On 06/11/26 at 11:22 AM, the surveyor toured the D unit pantry. The fridge temperature was observed to be 48 degrees Fahrenheit (F). On 06/11/26 at 10:04 AM, during an interview the FSD stated that the kitchen staff were responsible for checking dates, labels and temperatures in the pantries located in the nursing units. On 06/18/26 at 9:50 AM, during an interview the LNHA stated that food should have been refrigerated at a temperature no greater than 41 degrees F to prevent the potential spoilage of food. A review of the facility's Nutritional Services policy, dated 02/01/26, included the following guidance:1.) All food items will be stored at least 6 inches off the ground and 18 inches from the ceiling. 2.) Thermometers shall be present inside each cooler/freezer.3.) All refrigerated storage must be maintained at or below 41 degrees Fahrenheit, unless otherwise specified by law. NJAC 8:39-17.2(g)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to maintain a homelike environment that was clean, safe, and sanitary. This deficient practice was identified for 1 of 3 Units (200 Unit) and was evidenced by the following: On 06/12/26 at 9:25 AM, the surveyor observed a white sign posted on the bathroom door of room [ROOM NUMBER] on the 200 Unit that read, Do Not Use Sink Out of Service. The bathroom sink was actively dripping water. A black trashcan, and a pink basin had been placed beneath the sink to collect the leaking water. Both containers were overflowing, resulting in water accumulation on the bathroom floor. On 06/12/26 at 9:40 AM, during an interview with the surveyor, the Licensed Practical Nurse/Unit Manager (LPN/UM) reported that the bathroom sink had been dripping water for approximately three days and that a maintenance request had been submitted through the facility's electronic maintenance system for repair. The LPN/UM further indicated that the sink should not be dripping water due to safety concerns and the potential risk of resident falls. On 06/12/26 at 10:03 AM, during an interview with the surveyor, the Maintenance Director (MD) reported that a work order had been entered into the facility's electronic maintenance system approximately two to three days ago. He indicated that the water had been shut off the previous day and was unsure how it had been turned back on. The MD further explained that the bathroom sink should not have been leaking water and was unsure why the leak had continued. On 06/12/26 at 11:42 AM, during an interview with the surveyor, the Licensed Nursing Home Administrator (LNHA) stated that water should not have been dripping from the bathroom sink. The LNHA added that, just as a homeowner would not want a sink dripping in their house, the facility should not have had a leaking sink. A review of the facility's Quality of Life - Homelike Environment, policy revised September 2025 revealed that, When repairs are needed in certain areas, the maintenance department will be notified and will address them in a reasonable time. N.J.A.C. 8:39-31.4(a)

Based on observation, interview, record review, and review other facility documentation, it was determined that the facility failed to properly secure medications for 1 of 26 residents (Resident #2) sampled. This deficient practice was evidenced by the following: On 06/11/26 at 10:24 AM, the surveyor observed Resident #2 was not in his/her room, but there were medications left on the resident's dresser - an umeclidinium bromide inhaler, a fluticasone propionate nasal spray, an albuterol sulfate nebulizer solution and a budesonide nebulizer solution. On 06/11/26 at 10:26 AM, the surveyor interviewed Registered Nurse (RN) #1 who stated that medications should be secured in the medication cart when not in use. The RN further stated that she did not have any residents on her assignment that were allowed to self-administer medications. The RN explained that it was important to return multi-dose medications back to the medication cart to prevent misuse by other residents. At that time, RN #1 accompanied the surveyor to Resident #2's room and acknowledged the medications left on the dresser. The RN explained that she administered the inhaler and nasal spray to Resident #2, but that the resident left the facility with family and wanted to take the nebulizer treatments upon return. The RN then stated she should have secured the inhaler, nasal spray, and two nebulizer solutions in the medication cart when they were not in use. The surveyor reviewed the medical record for Resident #2. A review of the admission Record, and admission summary, revealed the resident had diagnoses which included, but were not limited to, chronic bronchitis, chronic obstructive pulmonary disease (COPD), and respiratory conditions due to smoke inhalation. A review of the quarterly Minimum Data Set (MDS), an assessment tool, dated 03/10/26, included the resident had a Brief Interview for Mental Status score of 15 out of 15, which indicated the resident's cognition was intact. A review of the individual comprehensive care plan (ICCP) included a focus area, dated 12/20/24, that the resident was at risk for respiratory compromise related to COPD and chronic bronchitis. Interventions included: Administer medication/puffers as ordered and administer nebulizer treatments as ordered. The ICCP did not include interventions that the resident was able to self-administer medications or keep medications stored within his/her room. A review of the Order Summary Report, as of 6/11/26, included the following physician orders (PO):A PO, dated 09/19/25, for albuterol sulfate nebulization solution 2.5 milligrams (mg)/3 milliliters (ml), inhale 3 ml orally via nebulizer three times a day for COPD.A PO, dated 12/11/25, for budesonide suspension 0.5 mg/2 ml, inhale 2 ml orally every 12 hours for wheezing related to chronic bronchitis and COPD.A PO, dated 09/19/25, for fluticasone propionate nasal suspension 50 micrograms (mcg) 1 spray in both nostrils one time a day for nasal congestion.A PO, dated 09/19/25, for umeclidinium bromide inhalation aerosol powder 62.5 mcg, inhale 1 puff orally one time a day related to COPD. On 06/11/26 at 10:50 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) who stated that medications should be secured within the medication cart or medication room when not in use. The LPN/UM further stated that the nurse should not leave medications at the bedside unless the resident was approved to self-administer medications. At that time, the surveyor informed the LPN/UM of the medications left in Resident #2's room, and the LPN/UM stated the nurse should have administered and returned the multi-dose medications to the cart to prevent other residents from having access to the medications. On 06/11/26 at 11:08 AM, the surveyor interviewed the Director of Nursing (DON) who stated that after administration, multi-dose medications should be secured in the medication cart in order to properly store medication for the safety of other residents. At that time, the surveyor informed the DON of the medications left in Resident #2's room, and the DON stated the nurse should not have left unopened nebulizer solutions in the resident's room and she should have returned the multi-dose inhaler and nasal spray to the medication cart. A review of the facility's Medication Storage policy, dated January 2026, included: Medications housed on our premises are stored in the medication carts and or medication rooms according to State, Federal, and the manufacturer's recommendations. NJAC 8:39-29.4(h)

Complaint: NJ186923, NJ186877 Based on observation, interviews, medical record review, and review of other pertinent facility documentation on 6/04/2025 and 6/09/2025, it was determined that the facility failed to ensure a resident's movement in and out of bed was not restricted. The Certified Nursing Assistant (CNA) placed a floor mat against the right quarter side rail that extended to the foot of the bed. The CNA then placed a bedside tray table and wheelchair against the floor mat to hold it in place along the right side of the bed. This restricted the resident's ability to move legs on the right side of the bed. This deficient practice was identified for 1 of 3 sampled residents ( Resident #2) and was evidenced by the following: According to the Facility Reportable Event (FRE), a New Jersey Department of Health (NJDOH) document used by the healthcare facilities to report incidents dated 5/30/2025, with an event date of 5/30/2025 and a time of event of 02:10 A.M., revealed that the family alleged that a mattress was against the resident's bed during the night. According to the video from the monitor placed in the room by the family, which was captured on 5/30/2025 during the 11 P.M. - 7 A.M. shift, the assigned CNA for Resident #2 is seen placing the floor mat on the right side of the bed, which extended to the foot of the bed. The CNA then secured the floor mat against the right side of the bed with a bedside tray table and wheelchair. The CNA was suspended pending the investigation. The Licensed Practical Nurse, LPN#5, failed to return phone calls to the facility. According to the admission Record, Resident #2 was admitted to the facility with diagnoses which included but were not limited to Insomnia and Anxiety. A review of the Minimum Data Set (MDS), an assessment tool dated 05/30/2025, Resident # 2 had a Brief Interview of Mental Status (BIMS) score of 3 out of 15, which indicated the resident was severely cognitively impaired. The MDS also showed Resident #2 depended on staff for toileting. A review of the Resident's Care Plan (CP) initiated on 5/28/2025 revealed under Focus: that Resident #2 is at risk for falls due to a history of falls, and on 5/29/2025, the family requested the left side of the bed against the wall. The CP initiated 5/29/2025, showed under Interventions, included but were not limited B/L (bilateral) ¼ siderails for sense of security as requested by family and left side of bed against the wall per family request; out of bed in gerichair when in the room; Provide safety mat on the right and left side of the bed. 5/28/2025: maintain bed in low position. On 5/27/2025, the resident was moved to a room closer to the nurses' station for increased visual monitoring. On 6/4/2025, the DON provided the surveyor with the assignment sheet from 5/29/2025 for Unit D. A review of the facility's Assignment Sheet for 5/29/2025, on the 11:00 P.M. to 7:00 A.M. shift revealed that CNA #1 and LPN #5 were assigned to the D unit and Resident #2. During an interview on 6/4/2025 at 10:35 A.M., LPN #1 stated I was made aware (of the incident) by resident #2's [family], who said the CNA had put a mattress against the bed, and there is no reason to put a mattress like that, its not part of the policy. During a telephone interview on 6/4/2025 at 12:13 P.M., the Licensed Practical Nurse Supervisor ( LPNS) stated, I believe (LPN#5) took care of the resident that night; she did not convey [that] the resident was anxious or needed any help. Yes, it would be a restraint if it was placed on the side of the bed and the resident couldn't move. I seen a clip that showed the mattress was on the side of the bed. 6/4/2025 at 12:04 P.M., a call was placed to LPN #5, and a voicemail message was left on the phone. Currently, at this time, no return response was received. During a telephone interview on 6/4/2025 at 12:28 P.M., CNA# 1 stated between 11:00 and 11:30 P.M. I seen the resident in room . and seen his/her legs out of the bed. I went into the room and put feet up and put the mattress up, the full size gel mattress, against the bed and moved the nightstand all the way up, parallel to the resident's (Resident #2) head to keep it in place and for the bottom, I put the wheelchair there so he/she can't fall. I checked on [resident] every 2 hours. At 6:00 A.M., I removed the mattress. Yes, that is a restraint if [resident] cannot get out. During a telephone interview on 6/4/2025 at 1:23 P.M., Resident #2's family member stated they had set up the camera on the nightstand, which looks like an alarm clock. During an interview on 6/4/2025 at 2:18 P.M., with the Director of Nursing (DON) in the presence of the Licensed Nursing Home Administrator (LNHA), the DON stated, I seen a video of the mattress against the bed throughout the night. The mattress was placed for the safety of the resident. It's a restraint if the resident could not get out willingly or freely. The DON also stated that the mattress should be on the floor, but it was used as a bumper. During the same interview, the LNHA stated, no, the mattress should not be like that against [ his/her] bed, it should be on the floor. A review of the facility policy titled Restraint Free Environment dated 8/2024 revealed the following: Under Policy: included Physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily . Under Compliance Guidelines: revealed a. The right to be free from any physical or chemical restraint imposed for the purpose of discipline or convenience, and not required to treat the residents medical symptoms. N.J.A.C.: 8.39- 4.1 (6)

Based on observation, interview, and record review, it was determined that the facility failed to a.) maintain kitchen equipment in a clean and sanitary manner and b.) maintain pantry equipment in a clean and sanitary manner on 3 of 3 units. The evidence was as follows: On 2/19/25 at 9:31 AM, the surveyor toured the kitchen in the presence of the Food Service Director (FSD) and observed the following: 1. The stand mixer was covered with a clear plastic bag which indicated that it was clean. The FSD removed the bag and the connecting bearing that holds the mixer attachment had hard dried white sediment on it. The FSD was able to wipe it off with a gloved hand. The FSD acknowledge it was not properly cleaned. 2. The can opener blade was worn, discolored, and had a rolled pointed edge. The FSD acknowledged it look like it had not been changed in a while and that it needed to be to prevent injury, metal splintering and cross contamination of food particles. 3. The microwave interior ceiling was covered with dried stuck on debris in a range of different colors. The FSD acknowledged and stated, it was not cleaned according to policy. On 2/19/2025 at 9:45 AM, the surveyor interviewed the FSD, who stated the mixer, microwave, and can opener blade did not meet her's or the facility policy's expectations. The FSD acknowledged that the equipment should have been cleaned and maintained in a sanitized way to prevent food borne illness and contamination. On 2/21/25 at 9:28 AM, in the presence of the Director of Housekeeping (DH), the surveyor observed the following: 1. The B-unit pantry had debris on the counter, in one cabinet drawer, and on two lower cabinets. The gaskets on the refrigerator door had particle buildup of white and brown debris in the gasket folds. 2. The C-unit pantry had a water dispenser that required maintenance that was indicated by the flashing wrench on the electronic screen. Two cabinet drawers had white and black sediment and debris on the interior portion. The refrigerator gaskets had debris inside of the folds. 3. The D-unit pantry had stains and debris in several cabinet drawers and on the counter. The gasket on the refrigerator door had debris in the folds, a tare in the gasket on the top of the door corner and the gasket at the base of the refrigerator door was covered with black discoloring, torn, and falling off the refrigerator. On 2/19/25 at 9:50 AM, the surveyor interviewed the HD, who acknowledged that the pantry equipment should have been cleaned and maintained in a sanitized way to prevent food borne illness and contamination. On 2/25/25 at 09:30 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), who both acknowledged the surveyor's concerns. No additional information was provided. A review of the facility's General Kitchen Sanitation Policy, dated 8/2024, included clean and sanitize all food preparation areas after use .keep food contact surfaces of all cooking equipment free of encrusted grease deposits and other accumulated debris . A review of the facility's Nursing and housekeeping and dietary Policy, dated 1/2025, revealed ensure all pantry areas in the facility are maintained in a clean and sanitary condition, in compliance with NJDOH and CMS infection control regulations, to prevent contamination and ensure resident safety .countertops, sinks and high touch surfaces to wiped and disinfected daily .refrigerators must be fully cleaned and sanitized .cabinets and storage shelves must be emptied, wiped and reorganized .any maintenance issues must be reported immediately to the maintenance department . NJAC 8:39-17.2(g)

Based on observation, interview, and record review it was determined the facility failed ensure a Preadmission Screening and Resident Review (PASARR) was completed accurately for a newly admitted resident. This deficient practice was identified for 1 of 2 residents reviewed for PASARR (Resident #9), and was evidenced by the following: On 2/19/25 at 11:10 AM, during the initial tour of the facility, Resident #9 was observed in the day room. A review of the Admission Record face sheet (an admission summary) indicated Resident #9 had medical diagnoses which included but were not limited to; diabetes (high blood sugar), respiratory conditions due to smoke inhalation, bipolar disorder, schizophrenia, and heart failure. A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated 12/19/24, revealed the resident had a Brief Interview of Mental Status score of 11 out of 15, meaning the resident had moderate cognitive impairment. A review of Section J Active Diagnoses revealed that the resident had diagnoses including bipolar disorder and schizophrenia. A review of the resident's individualized comprehensive care plan included a focus area dated 12/14/24, for multiple medications related to diagnoses of major depressive disorder, schizophrenia, and bipolar disorder. The ICCP included an additional focus area dated 12/14/24, that the resident utilized psychotropic medications related to schizophrenia and bipolar disorder. On 2/21/25 at 9:15 AM, the facility provided the surveyor with the resident's PASARR Level I. A review of the PASARR screening, section two titled Mental Illness Screen was marked No for the resident having a diagnosis or evidence of a major mental illness or evidence of a major mental illness. On 2/25/25 at 10:30 AM, during an interview with the Director of Nursing (DON), the DON told the surveyor that the Social Worker who was responsible for the PASARR was Very good, I don't know what happened, she missed it. I think she was out of work at the time. A review of a facility's Resident Assessment-Coordination with PASARR policy dated revised 7/2024, included the Social Services Director shall be responsible for keeping track of each resident's PASARR evaluation report . NJAC 8:39-27.1 (a)

Based on observation, interview, and review of pertinent facility documents, it was determined the facility failed to revise an individual comprehensive care plan (ICCP) with the resident's personal preference for incontinence care and the need for incontinence briefs. This deficient practice was identified in 1 of 9 residents observed for incontinence care (Resident #35), and was evidenced by the following: On 2/19/25 at 9:55 AM, during initial tour of the facility, the surveyor accompanied by the Certified Nursing Aide (CNA), observed incontinence care for Resident #35. The surveyor observed that the resident had an adult incontinence brief on with a pull-up incontinence brief on top. At that time, the CNA informed the surveyor that it was the resident's preference to wear two incontinence briefs. The surveyor asked the resident if they had a preference to be double briefed, and the resident stated yes, due to the feeling of better support. On 2/21/25 at 11:22 AM, the surveyor reviewed Resident #35's electronic medical record (EMR) and the following was indicated: A review of the Admission Record face sheet (an admission summary) indicated that the resident was admitted to the facility with diagnosis which included but was not limited to; major depressive disorder, type two diabetes, and chronic kidney disease. A review of the resident's most recent comprehensive Minimum Data Set (MDS), an assessment tool assessment dated [DATE], reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated fully intact cognition. The MDS further revealed that the resident was dependent on staff for toileting hygiene and was always incontinent of bowel and bladder. A review of the ICCP included a focus area dated 1/24/25, and revised 2/7/25, for a risk for skin breakdown and/or have actual skin impairment related to bladder incontinence, bowel incontinence, and impaired mobility. The ICCP included an update dated 2/19/25, the same day as surveyor inquiry, that the resident preferred and requested to wear an adult brief with a pull-up over it. On 2/21/25 at 11:57 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) in the presence of the Nursing Educator (NE). The LPN/UM stated that the CNA's responsibilities when it came to incontinence care was to ensure the residents were checked every two hours and to treat the residents with respect. The LPN/UM stated that residents should not, under normal circumstances, be double briefed as it could cause skin irritation, which could lead to skin breakdown and infection, as well as take away from the resident's dignity. The LPN/UM further stated that residents had the right to prefer to wear double briefs, but nursing staff were responsible to educate and update the care plan to include the resident's preference, and the CNAs were expected to communicate with the nurses to ensure it was completed. The LPN/UM acknowledged that Resident #35's care plan was not updated to indicate the resident's preference for double incontinence briefs until after the surveyor's observation and inquiry. On 2/21/25 at 12:23 PM, the surveyor interviewed the Director of Nursing (DON), who stated that residents had the right to their preference in care, including to be double briefed, but nursing was responsible to educate the resident and family, and to update the resident's care plan timely the moment the resident's preference was known or within 24 hours. On 2/21/25 at 12:55 PM, the surveyor observed Resident #35 in their room watching television. The resident informed the surveyor that they had been at the facility for approximately a month and that they informed the nurse that passes the medication that they preferred to be double briefed when they were first admitted to the facility. On 2/24/25 at 12:29 PM, the surveyor interviewed the DON, who confirmed that Resident #35 was cognitively intact and able to make their needs and preferences known. On 2/25/25 at 9:30 AM, the Licensed Nursing Home Administrator (LNHA), in the presence of the survey team, acknowledged that Resident #35's care plan should have been updated prior to surveyor inquiry and observation, and that the resident's preference should have been communicated by the nursing staff. A review of the facility's Comprehensive Care Plans policy with a last revised date of 7/2024, included the care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally competent and trauma informed . NJAC 8:39-27.1(a)

Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to ensure that proper incontinence care was provided to dependent residents. This deficient practice was identified for 1 of 9 residents observed for incontinence care (Resident #43), and was evidenced by the following: On 2/19/25 at 9:55 AM, during initial tour of the facility, the surveyor accompanied by the Certified Nursing Aide (CNA), observed incontinence care for Resident #43. The surveyor observed that the resident had an adult incontinence brief on with a pull-up incontinence brief on top. The surveyor asked the resident if they had a preference to be double briefed, and the resident shrugged their shoulders indicating they did not know. On 2/19/25 at 10:09 AM, the surveyor interviewed the CNA, who stated that residents should not be double briefed and that residents who required incontinence care should have been checked every two hours at a minimum to ensure they were dry. On 2/21/25 at 11:27 AM, the surveyor reviewed Resident #43's electronic medical record (EMR) and the following was indicated: A review of the Admission Record face sheet (an admission summary) indicated that the resident was admitted to the facility with diagnosis which included but was not limited to; dementia, chronic kidney disease, and need for assistance with personal care. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 1/29/25, reflected the resident had a Brief Interview for Mental Status (BIMS) score of 7 out of 15, which indicated the resident had severe cognitive impairment. The MDS further revealed that the resident was dependent on staff for toileting hygiene and was frequently incontinent of bowel and bladder. A review of the individualized comprehensive care plan (ICCP) included a focus area with an initiation date of 1/28/25, and a revision date of 1/29/25, that the resident was at risk for activities of daily living (ADL) self-care deficit related to physical limitations. On 2/21/25 at 11:57 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) in the presence of the Nursing Educator (NE). The LPN/UM stated that CNA's responsibilities when it came to incontinence care was to ensure the residents were checked every two hours and to treat the residents with respect. The LPN/UM stated that residents should not, under normal circumstances, be double briefed because it could cause skin irritation, which could lead to skin breakdown and infection, as well as take away from the resident's dignity. On 2/21/25 at 12:23 PM, the surveyor interviewed the Director of Nursing (DON), who confirmed that residents should not be double briefed as it could take away from their dignity and could cause skin breakdown. The DON confirmed that Resident #43 was unable to verbalize preferences and should not have been double briefed. On 2/25/25 at 9:30 AM, the Licensed Nursing Home Administrator (LNHA), in the presence of the survey team, acknowledged that residents should not have been double briefed. After multiple requests from the surveyor, the facility was unable to provide a policy that included the proper general incontinence care procedure. NJAC 8:39-27.1(a); 27.2(h)

Based on observation, interview, and the review of pertinent facility documentation, it was determined that the facility failed to a.) provide supportive rational for starting a new antianxiety medication and b.) document targeted behaviors for a resident on psychoactive medication. This deficient practice was identified for 1 of 3 residents reviewed for psychoactive medication use (Resident #88), and was evidenced by the following: A review of the admission Record face sheet (admission summary) indicated that Resident #88 was admitted to the facility with the diagnoses which included but was not limited to; dementia and unspecified psychosis not due to a substance or known psychological condition. A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated 12/26/24, reflected that Resident #88 had severe cognitive impairment and did not exhibit any behaviors. The MDS also indicated that the resident required partial assistance from another person to complete activities of daily living (ADLs). On 2/19/25 at 11:06 AM, during initial tour, the surveyor observed Resident #88 sitting up in the wheelchair in the dining room, pleasantly confused and coloring. The resident was unable to be interviewed due to impaired cognitive. The surveyor reviewed the resident's electronic medical record (EMR) which revealed the following: A review of the Physician Order Summary Report (POSR) dated 2/7/25, reflected that Resident #88 was ordered the antianxiety medication lorazepam (Ativan) 0.5 milligram (mg) tablet; administer 1 tablet by mouth every 12 hours as needed for anxiety for 14 days. A review of the nursing Progress Note (PN) dated 2/7/25, indicated that the nurse discussed with the Advanced Nurse Practitioner (ANP) the resident's behaviors of frequent and repeatedly yelling out at night and that staff were having difficulty redirecting the resident's behavior. The note reflected that the APN discussed with the resident's Responsible Party (RP) and ordered the antianxiety medication Ativan 0.5 mg as needed (prn) for 14 days. A review of the the Progress Notes from 2/1/25 until 2/7/25, prior to the order for the Ativan, there was no supporting documentation on the evening or night shifts that the resident was exhibiting behaviors such as yelling, and that staff were having difficulty redirecting the resident's behavior. A review of the February 2025 Medication Administration Record (MAR) revealed that the resident received Ativan on 2/10/25, 2/19/25, and 2/20/25. A review of the corresponding PN dated 2/10/25, 2/19/25, and 2/20/25, included no clinical behavior documentation to support the administration of the antianxiety medication on those dates. A review of Resident #88's individualized comprehensive care plan (ICCP) indicated that the staff focused on the use of psychotropic medication for the targeted behaviors such as yelling to the point of exhaustion. Interventions included: medications were to be administered as ordered and to monitor and document for side effects and effectiveness of medications; monitor/record occurrences for target behavior symptoms such as screaming, violence, aggression toward staff and others and document as per the facility policy. A review of the Psychotropic Monthly Review dated January 2025, reflected that the resident had zero episodes of targeted behaviors such as yelling to the point of exhaustion and hallucinations. A review of the Psychiatric Consult (PC) dated 2/7/25, reflected that the resident was seen for a psychiatric follow-up and medication management. The Psychiatrist documented that the resident was re-examined and that staff had reported that the resident had periods of behavior dyscontrol and was more redirectable during the daytime hours. The documentation indicated that the resident had no hallucinations, delusions, or other symptoms of psychotic process that were reported. The Psychiatrist also documented that the resident had no manic symptoms that were reported and no side effects to medications. The surveyor reviewed Resident #88's progress notes which did not reflect that the resident's targeted behaviors of yelling were being documented or that the staff had attempted non-pharmacological approaches to manage the behaviors prior to obtaining a physician's order for the use of an antianxiety medication. On 2/20/25 at 12:15 PM, the surveyor interviewed the Licensed Practical Nurse (LPN), who stated that when any resident in the facility who was started on new psychotropic medication, the nurse assigned to the resident was required to document what behaviors the resident was exhibiting. The LPN stated that behaviors were documented by exception; that before a psychotropic medication was ordered, there should be documentation in the resident's medical records that the resident was exhibiting behaviors, what the behaviors were, and non-pharmacological interventions that were attempted prior to administration of psychotropic medications. The LPN stated that after the resident was started on a psychotropic medication, the nurses were to document for 14 days after initiating the new psychotropic drug. On 2/20/25 at 12:19 PM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM), who stated that when a resident was on a psychotropic medication, that documentation included monthly psychotropic notes. The LPN/UM stated that the Psychiatrist was updated every Friday when they came in to see the residents. The LPN/UM explained that she had documented on 2/7/25 at 4:09 PM, that Resident #88 was having increased yelling and staff had difficulty redirecting the resident during the night hours. The surveyor asked the LPN/UM who reported those behaviors because a review of the clinical documentation did not reflect that the resident was exhibiting any behaviors at night prior to the Ativan being ordered. The LPN/UM stated that it was reported to her by the resident's roommate and not by the clinical staff. The surveyor asked the LPN/UM if the resident was assessed for pain or any other reasons that they may have been yelling, and the LPN/UM stated that she did not document that and could not recall. The LPN/UM confirmed it would have been important to document if any non-pharmacological interventions were attempted prior to starting the resident on Ativan. The LPN/UM reviewed the resident's nursing progress notes and the 24-hour report and could not find any documentation from the clinical staff that the resident was exhibiting yelling at night repeatedly and was difficult to redirect. The LPN/UM stated that behavior monitoring was done by exception, and that documentation would only occur if the resident was exhibiting behaviors. The LPN/UM stated that after starting any new medication, the resident was monitored for 14 days. The LPN/UM reviewed the resident's medical record and could not find any documentation indicating that the use of the antianxiety medication Ativan was being monitored for effectiveness after use. The surveyor reviewed the facility 24-hour report from 2/1/25 until 2/7/25, and there was no documentation that Resident #88 was exhibiting the behaviors such as yelling or screaming or that the resident was difficult to redirect. On 2/21/25 at 8:49 AM, the surveyor interviewed the primary care Certified Nursing Aide (CNA), who stated that the resident was confused but was able to recognize him. The CNA stated that the resident would resist care at times, but was easy to redirect. The CNA stated that the resident exhibited more behaviors at night such as resisting care or screaming, but he did not know how often it had occurred. The CNA continued to explain that when Resident #88 resisted care, he just talked the resident through it, and then the resident would then allow care to be performed. The CNA also added that the resident had behaviors such as screaming, but did not exhibit it all the time. On 2/25/25 at 9:32 AM, the surveyor interviewed the Director of Nursing (DON), who stated that she had reviewed the resident's medical record and agreed that there was no documentation that the resident was exhibiting behaviors such as screaming at night prior to obtaining an order for the antianxiety medication Ativan. The DON also confirmed that there was no documentation of any non-pharmacological interventions initiated prior to administration of the medication. A review of the facility's Use of Psychotropic Drugs policy dated 1/2025, included that a resident who had not used psychotropic drugs were not to be given these drugs or prn psychotropic medications unless the medication was necessary to treat a specific condition diagnosed and documented in the clinical record . NJAC 8:39-29.3(a); 33.2 (a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure Enhanced Barrier Precautions (EBP) were maintained while providing direct resident care in accordance with infection control standards of practice and facility policy. The deficient practice was identified for 1 of 9 residents observed for incontinence care (Resident #105), and was evidenced by the following: A review of Resident #105's Admission Record face sheet (admission summary) indicated that the resident was admitted to the facility with dementia and rheumatoid arthritis (RA). A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 12/12/24, indicated that the resident had severe cognitive impairment and required maximum assistance with all aspects of activities of daily living (ADLs). On 2/19/24 at 9:55 AM, the Licensed Practical Nurse/Unit Manager (LPN/UM) accompanied the surveyor to conduct incontinent rounds for Resident #105. Prior to entering the resident's room, the surveyor observed signage posted on the door that indicated that a resident in that room was on Enhanced Barrier Precautions (EBP). There was also a personal protective equipment (PPE) caddy hanging on the door which contained gloves, isolation gowns, and masks. The resident was observed lying in bed and was unable to be interviewed due to cognitive impairment. The surveyor observed that Resident #105 was lying on an air mattress and was wearing green foam booties to bilateral lower extremities. The LPN put on gloves and proceeded to turn the resident to check the resident's incontinence briefs and stated that the resident was clean and dry. The LPN/UM was only wearing gloves at that time. The LPN/UM performed hand hygiene after resident care. The surveyor asked the LPN/UM if the resident was on EBP precautions, and LPN/UM responded that Resident #105 was on EBP due to a wound. The LPN/UM acknowledged that she did not apply an isolation/protective gown prior to performing direct care for the resident. The LPN/UM stated that the gown was important to apply to protect the resident from any microorganisms that she may have had on her clothing that could be transferred to the resident and cause an infection. On 2/21/25 at 8:54 AM, the surveyor interviewed the primary care Certified Nursing Aide (CNA), who stated that Resident #105 was cognitively impaired and required total care with all aspect of ADLs. The CNA stated that the staff were required to apply (don) PPE prior to providing direct resident care. The CNA stated that Resident #105 was on EBP precautions because the resident had a wound on their right buttocks. On 2/21/25 at 11:16 AM, the surveyor interviewed the Infection Preventionist (IP), who stated that the LPN/UM should have worn an isolation gown when performing direct care with Resident # 105. The IP stated that the importance of wearing PPE while caring for a resident with open access to the body was to protect the resident from any bacteria that could be transferred from the caregivers' clothes to the resident. A review of Resident #105's individualized comprehensive care plan (ICCP) dated 7/15/24, reflected that the resident was on EBP related to having a wound. The interventions included that staff wore a gown and gloves when providing high contact activity such as dressing, bathing, transferring when high contact is anticipated, providing hygiene, changing linens, changing briefs, assisting with toileting, device care or wound care. A review of the Physician's Order Summary Report dated 12/13/24, included a physician's order (PO) to maintain EBP due to the residents wound every shift. A review of the Medication Administration Record (MAR) dated 12/13/24, reflected an PO to maintain EBP due to wound every shift. On 2/25/25 at 9:40 AM, the Director of Nursing (DON) confirmed that all nurses should don the proper PPE that was specified by the signage on the resident's door prior to providing direct resident care for a resident that was on EBP. A review of the facility's Enhanced Barrier Precautions dated 3/21/24, included EPB was utilized for the prevention of transmission of targeted multi-resistant organism to keep residents safe. The policy indicated that EBP is initiated for residents meeting the criteria such as wounds and indwelling medical devices. Implementation of EBP specified that gowns and gloves be available for use during high contact activities . NJAC 8:39-19.4 (a); 27.1(a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) maintain multiuse food-contact surface cutting board in a manner to prevent microbial growth; b.) store, label, and date potentially hazardous foods to prevent food-borne illness; and c.) perform hand hygiene in accordance with infection control standards. This deficient practice was evidenced by the following: On 1/13/23 at 9:14 AM, the surveyor toured the kitchen with the Food Service Director (FSD) and observed the following: 1. In the walk-in refrigerator, one opened container of ricotta cheese. The container was not labeled when opened or when to use by. The packaging indicated best quality is three days. The FSD acknowledged the container was not labeled when opened or when to discard. 2. In the reach-in refrigerator, seven health shakes not dated; one health shake dated 1/2/23; and two health shakes dated 1/9/23. The FSD stated that the health shakes came in frozen and when pulled from the freezer, they needed to be used or discarded within fourteen days. The FSD stated the 1/2/23 and 1/9/23 were the dates the health shakes should have been discarded. 3. On a storage rack, the surveyor observed one large red, one large brown, one large beige, three large white, one medium red, two light blue, and one large yellow cutting boards. The cutting boards were all deeply pitted and discolored. The FSD confirmed the kitchen should not be using these cutting boards because the pitting and discoloration could lead to bacterial growth. On 1/19/23 at 12:00 PM, the surveyor conducted a follow-up kitchen inspection and observed a Dietary Aide (DA) mop the kitchen floor, remove her gloves, and performed hand hygiene using soap and water. The surveyor observed the observed the DA turn the water on, wet her hands, lathered her hands with soap outside the flow of running water for six seconds and then began rubbing her hands under the flow of running water. At this time, the surveyor asked the DA the process of washing your hands using soap and water. The DA responded that you lathered your hands with soap for twenty seconds in the flow of running water. The surveyor asked the DA to show them the hand washing process and she again lathered her hands with soap outside the flow of running water for six seconds. At this time, the Regional FSD was present, and the surveyor asked him what the process for washing your hand using soap and water? The Regional FSD responded my understanding the whole process twenty seconds. When asked how long outside do you lather your hands with soap outside the flow of water? The Regional FSD responded there was no set time, the whole process was twenty seconds. Then the Regional FSD located hand washing instructions on the wall by the dish station and stated you lather your hands with soap for twenty seconds outside the flow of running water. On 1/19/23 at 12:22 PM, the surveyor interviewed the Director of Nursing (DON) regarding the hand washing process using soap and water. The DON stated that you lathered your hands outside the flow of running water for twenty seconds per the Centers for Disease Control (CDC) guidelines. On 1/24/23 at 11:12 AM, the Licensed Nursing Home Administrator (LNHA) in the presence of the DON and survey team, acknowledged these findings. A review of the undated facility provided Label and Dating policy included . all foods stored in the refrigerator or freezer will be covered, labeled and dated using the use by date to ensure proper rotation . A review of the undated facility provided Food Storage and Retention Guide included . thawed health shakes fourteen days after thawing or removing from freezer. A review of the facility provided Hand Washing policy dated 11/4/22, included . hand washing procedures: wash hands with clean running water; apply adequate amount of soap to hands; lather your hands by rubbing them together with soap. Be sure to lather the back of your hands between your fingers and your nails; scrub your hands for at least twenty seconds; rinse your hands well under running water . NJAC 8:39-17.2(g)

Based on observation, interview, and review of facility documentation, it was determined that the facility failed to follow proper infection control procedures by not doffing (remove) personal protective equipment (PPE) to prevent the spread of infection for 2 of 6 Resident's on transmission based precautions (Resident #6 and #7). This deficient practice was evidenced by the following: On 4/28/2020 at 8:10 AM, the Director of Nursing (DON), in the presence of the Licensed Nursing Home Administrator (LNHA) and the survey team, stated during entrance conference that the facility had four cohorting groups for the residents based on the resident's COVID status. The DON stated that residents that were grouped in Cohort #2 were residents that were exposed to COVID but were asymptomatic and tested COVID negative. The facility designated those rooms to C-wing and one room on B-wing. The DON stated that the PPE required in Cohort #2 was an N95 (respirator mask), isolation gown, goggles or face shield, and gloves were to be worn in these rooms and that the gown and gloves were to be doffed (removed) prior to exiting the room. At 11:19 AM, the surveyor interviewed the Licensed Practical Nurse (LPN)/Unit Manager (UM) on C-wing who stated that the entire unit was considered PUI (Persons Under Investigation) because the residents were exposed to a staff member who tested COVID positive. The residents were placed on 14-day isolation and Transmission Based Precautions (TBP). At 11:26 AM, the surveyor observed a Housekeeper (HK) in the hallway between rooms [ROOM NUMBERS]. The HK was wearing a reusable isolation gown, gloves and a N95 mask. The HK stated to the surveyor that he was about to enter a room to mop the floor. The HK stated he changed the mop head and water after each room he cleaned. He further stated that he changed the gown and gloves after each room. At 11:32 AM, the surveyor observed the HK cleaning isolation room [ROOM NUMBER]. The HK was wearing a reusable isolation gown, gloves, mask, and goggles. The HK exited the room and proceeded to walk down the hallway in the direction of the nurse's station toward additional resident rooms. The surveyor stopped the HK to interview him and he stated he was waiting for the floor to dry in room [ROOM NUMBER] before he removed his gown. He then proceeded to remove the gown, roll it up and place it in a bin in the hallway labeled, soiled re-usable isolation gowns, and immediately used alcohol-based hand rub (ABHR) to clean his hands. When asked if he should have worn the soiled gown in the hallway after cleaning an isolation room, the HK replied, No. At 11:39 AM, the surveyor interviewed the LPN/UM who stated that in the hallway the required PPE in C-wing was a face shield or goggles and a N95 mask with a surgical mask over it, and that the hallways were considered clean areas. Resident rooms that had stop signs on the door required full PPE of gowns, gloves, N95 mask with surgical over it, and goggles or face shield. Any staff entering the room, donned the PPE prior to entering the room, and doffed the PPE prior to leaving the room. Handwashing should be performed immediately after the PPE was removed. The LPN/UM further stated that after exiting the resident's room, the HK should have doffed his gown and not been in the hallway wearing the gown and that the HK needed to be re-educated. At 11:46 AM, the surveyor observed the LPN/UM approach and instruct HK to remove the gown before leaving each room and to wash hands immediately. At 1:52 PM, the DON, in the presence of the LNHA and the survey team, stated that the HK was supposed to dispose of PPE before exiting an isolation room and should not be wearing contaminated PPE in the hallway. A review of the facility's COVID-19 Testing and Cohort Plan policy, last updated 9/23/2020, included that Cohort #2 were residents who were COVID-19 exposed. This cohort consists of symptomatic and asymptomatic patients/residents who test negative for COVID-19 with an identified exposure to someone who was positive. A review of the facility's Transmission Precautions- Droplet policy revised 3/10/20, under Procedure included: 3. Hand washing: Wash hands thoroughly between residents, after removing gloves, and before leaving resident room. Wash hands thoroughly after contact with any body substance, equipment, or articles contaminated with any body fluid. 4. Wear gloves when contact with any body substance is anticipated. 5. Wear gowns when working within three (3) feet of the resident or when providing direct care or contact. 6. Wear N- 95 or a face mask. 2. On 4/28/21 at 2:45 PM, the surveyor observed a female in a reusable yellow gown walking from the resident unit hallway to the reception desk at the main entrance. She removed the gown, rolled it up and handed it to the Receptionist who proceeded to put it in a garbage bag, tied off the bag and placed the bag under the desk. The Receptionist then used alcohol-based hand rub (ABHR). At the same time, the female proceeded to use ABHR and checked out on the kiosk and exited the building. The surveyor then interviewed the female who stated that she was a compassionate care visitor for her parent, Resident #6, who resided on the C-wing. The visitor stated that she was given an N95 and a robe at the front desk after she was screened and tested via the rapid antigen testing. She stated that she had been educated to put the gown and mask on and to wear it in the room of Resident #6. The visitor stated that she had not been educated to remove the gown prior to exiting the resident room. She added that she had been updated on the COVID-19 status in the building and that she was encouraged to conduct hand hygiene. The visitor also stated that she walked from Resident #6's room on C-wing, through the hallway where residents that were New Admissions resided, off the unit and down the hallway to the reception area wearing the gown and mask that she had worn in her parent's room, who was currently on TBP. She stated that she did not encounter any staff or residents upon leaving the room. At 2:48 PM, the surveyor interview the Receptionist who stated that the visitor was supposed to leave the reusable gown in a bin labeled soiled gowns that was outside the door of the unit and that it was not common practice to take a contaminated gown from a visitor while at the Reception desk. The Receptionist added that she will bring the bag with the gown to the laundry at the end of her shift. At 2:51 PM, the surveyor interviewed the RN/IP who stated that there was a container in the resident's room for contaminated gowns and that each visitor signs a consent form on the kiosk prior to visitation and that the Receptionist gives the visitor the required PPE. The RN/IP stated that the Receptionist had been trained to offer the PPE and that the visitor puts it on before they walk to the resident's room. She added that the routine of providing PPE to a visitor was to protect the residents and that she only went to her parent's room and returned because that was what they were told. When the surveyor asked how does she ensure that the visitor read and understood what was in the consent form the RN/IP stated, That is a good question. At 3:26 PM, the surveyor reviewed the facility form titled, Visitation Consent Form, which included: I/We may be required to wear additional PPE during bedside visitation and will properly dispose the PPE. Review of the facility policy titled, COVID-19: Essential Care and Compassionate Care Visitation with a last reviewed date of 4/4/21, read under requirements: *Compassionate visitation can occur at any time in the resident room during an outbreak. *Essential caregiver(s) and the resident are required to sign an informed consent form that they are going to visit. The informed consent form outlines that visitors and resident: a. Are aware of the possible dangers of exposure to COVID-19 for both the resident and the visitor during the visit. b. Will strictly comply with the facility policies during visitation. c. Must notify the facility if they test positive for COVID-19 or exhibit symptoms of COVID-19 within 14 days of visit. d. Received information and instruction from the facility regarding infection control practices, hand hygiene and personal protective equipment (PPE). At 3:39 PM, the LNHA stated that they always had the visitor's gown up because they were an outsider and it was the regular process up until two days ago to put the gown on and return it to the receptionist upon departure. We will need to re-educate the staff, families and Receptionist. N.J.A.C. 8:39 - 19.4

Based on observation, interview and record review, it was determined that the facility failed to ensure residents were served their meals in a dignified manner during meal services. This deficient practice was identified on 1 of 3 nursing units (B Wing) and was evidence by the following: 1. On 3/3/21 from 8:15 AM to 9:05 AM, the surveyor made the following meal observations in the dayroom on B Wing: There were ten residents observed, who were all socially distanced and wore surgical masks at dining tables. The Licensed Practical Nurse/Unit Manager (LPN/UM) stated that these residents were high fall risks and could not remain in their rooms for safety reasons. The LPN/UM stated that breakfast usually arrived around 7:45/8:00 AM. At 8:16 AM, the surveyor observed Resident #16 in the dayroom, communicate to the LPN/UM that they were hungry. The LPN/UM informed the resident that she was aware that they were hungry and breakfast would arrive soon. At 8:30 AM, the resident, watching other residents eat breakfast, communicated to the LPN/UM that they were hungry. At this time, the LPN/UM gave the resident some juice. At 8:44 AM, the resident received their breakfast tray. At 8:20 AM, the surveyor observed the dining truck arrive to B Wing and the food was immediately served by the nursing staff. There were ten residents sitting in the dayroom for breakfast. Six out of the ten residents received their meal trays and were eating breakfast. The LPN/UM stated that the other four residents' meal trays were on a separate truck. At 8:30 AM, Resident #77 was in the dayroom and stated that they were hungry. At this time, six other residents around him/her were all eating breakfast. At 9:05 AM, the resident received their breakfast tray. 2. On 3/3/21 between 1:00 PM and 1:48 PM, the surveyor made the following meal observations in the dayroom on B Wing: At 1:04 PM, the lunch trays arrived to B Wing's dayroom. Seven of the eleven residents were eating lunch. The four residents not eating lunch were waiting for their meals on a separate dining truck. At 1:14 PM, Resident #101, who was eating lunch, asked Resident #77 if they were not eating lunch today. Resident #77 responded that they were hungry, and waiting for lunch. At 1:26 PM, Resident #77 informed staff that they were hungry, and staff stated that the lunch trays were on the way. At this time, an Activity Aide began clearing the residents' meal trays that were already served lunch, who were finished eating. At 1:32 PM, one of the four residents (Resident #16) who was in the dayroom still waiting on lunch, received their meal tray. At 1:42 PM, an additional resident (Resident #40) arrived to the dayroom stating they were hungry. That resident self-propelled to a table with a resident currently eating lunch, and took the sherbet off of that resident's tray and began eating it. At 1:48 PM, the last resident in the dayroom who had not received a meal tray, Resident #85, received their lunch. 3. On 3/5/21 from 8:00 AM to 8:46 AM, the surveyor made the following meal observations in the B Wing dayroom: At 8:14 AM, the first meal truck arrived to B Wing. At 8:19 AM, the surveyor observed six of the ten residents in the dayroom receive their breakfast trays. At 8:22 AM, the surveyor observed three residents (Resident #13, #77, and #85), socially distanced and masked, sitting at one table. Resident #77 complained that they were hungry and asked staff for breakfast. The resident then stated to the other two residents that they were starving. At 8:27 AM, Resident #77 and #85 began banging their hands on the table shouting, We want food. Staff observed this, and no actions were taken. At 8:29 AM, Resident #85 told the Certified Nursing Aide (CNA) to go to the kitchen and tell them that we are hungry; The CNA did not respond. At 8:38 AM, the second meal truck arrived to B Wing. Residents #77 and #85 received their breakfast trays at 8:42 AM and Resident #13 received their breakfast tray at 8:46 AM. A review of the Meal Service list provided by the Licensed Nursing Home Administrator (LNHA) from entrance conference reflected that breakfast on the B Wing was served at 7:45 AM and lunch was served at 12:30 PM. The paper indicated to please allow fifteen minutes plus or minus on delivery times. On 3/9/21 at 9:16 AM, the LNHA in the presence of the Director of Nursing (DON), Assistant Director of Nursing (ADON), and survey team, stated that residents on B Wing should have been fed at the same time. At this time, the DON acknowledged that staff should have offered the residents who were expressing hunger something to eat at that time. A review of the facility's Nutritional Services policy dated 3/14/14 and revised date 3/9/15 included that the Dietary Department will develop an order of service for all meals which best suits the needs of the residents. The scheduled order will be followed. N.J.A.C. 8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to: a) properly store medication; and b) accurately administer medication for 2 of 2 residents during medication administration (Resident #37 and Resident # 44). This deficient practice was evidence by the following: 1. On 03/02/21 at 11:46 AM, on the B-Unit during medication administration, the surveyor observed LPN #1 walk into Resident #37's room to administer medication. LPN #1 placed the following items on the resident's bedside table: One [MEDICATION NAME] Flex Pen (insulin pen-a medication used to control blood sugar), which was stored in a clear bag, a glucometer, a container of glucose test strips, and an insulin lancet (a device used to puncture the skin to get a blood sample that is used to test glucose in the blood). LPN #1 stated that she had to get an alcohol pad before testing Resident #37's blood sugar. LPN #1 walked out of the room, then later returned, holding the alcohol pad in her hand. Resident #37 was alone in the room, and the items mentioned above remained on the bedside table out of sight of the nurse. According to the facility admission record, Resident #37 was admitted in 6/2020 with [DIAGNOSES REDACTED]. A review of the Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/21/20, revealed that Resident #37's cognition was intact. A review of the Physician order [REDACTED]. On the same day at 11:53 AM, the surveyor interviewed LPN #1, who stated, I should have brought everything with me. LPN #1 also mentioned that the facility's policy was not to leave medications at the bedside. On 03/05/21 at 12:22 PM, the surveyor interviewed the Infection Prevention Officer (IPO). The IPO stated that she was responsible for educating staff and for the completion of medication administration competencies. The IPO added that medication administration competencies consisted of handwashing, medication administration time, reading of medication, types of medication and how they were given, signing off of medications, storing medications, side effects, and what to monitor. IPO stated that medications should not be left at the bedside unattended, Because somebody may come in and take them. On the same day, at 1:51 PM, the surveyor interviewed the Administrator and Director of Nursing (DON) in the presence of the survey team. The DON stated that LPN #1 should have taken the [MEDICATION NAME]pen with her. The DON added that competency was an observation of skill and done with staff by the IPO. A review of the LPN #1 Orientation Checklist revealed a performance skill that consisted of Medication Administration: Medication Pass dated 12/9/20. A review of the facility's policy and procedure titled Medication Storage, created 11-17, read: Medications housed on our premises are stored in the medication carts and or medication rooms according to State, Federal, and the manufacturer's recommendations. All medications are stored in designated areas sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. A review of the facility's undated policy and procedure titled Medication Administration Procedures, read under Procedures A: Security: All medication storage areas (carts, medication rooms, central supply) are locked at all times unless in use and under the direct observation of the medication nurse/aide. On 03/8/21 at 1:35 PM, the surveyor interviewed the Consultant Pharmacist (CP), who confirmed that medications should not be left at the resident's bedside. 2. On 03/04/21 at 11:32 AM, the surveyor, observed LPN #2's medication cart located on B-Unit. Upon inspection, it revealed no Pantoprazole 40 mg available for Resident #44, yet the Medication Administration Record [REDACTED]. According to the facility admission record, Resident #44 was admitted in 9/2019 with [DIAGNOSES REDACTED]. A review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that Resident #44's cognition was severely impaired. A review of the Physician order [REDACTED]. At that time, the surveyor interviewed LPN #2, who stated that she had administered NAME] 40 milligrams (mg) to Resident #44. LPN #2 also mentioned that the medication was borrowed from Resident #70. LPN #2 stated that the process for acquiring medication when out of stock was to inform the pharmacy by fax and obtain the medication from the backup house stock locked on D-Unit and notify the physician. A Review of the POS [REDACTED]. The POS had a start date of 2/03/21 and no end date. At 12:00 PM, the surveyor interviewed the Unit Manager (UM), who stated that when a medication was not available, the process was to call the physician informing them that the medication was not available at the facility, receive orders whether to hold or give another medication and obtain the medication from the backup box located on D-Unit. The UM stated medications were not to be borrowed from other residents, and it was not good practice. The UM continued to mention that it was the ownership of the resident whose medication was borrowed from and that the resident can run out, resulting in the medication not being given as scheduled. The UM mentioned that documentation in the MAR indicated [REDACTED]. At 1:21 PM, the surveyor interviewed LPN #2 in the presence of the survey team. LPN #2 stated she would need to clarify the facility's borrowing protocol. LPN #2 mentioned that the nursing practice was not to borrow from other residents and that she did not check the medication backup box. At 1:41 PM, the surveyor interviewed the DON in the presence of the survey team. The DON confirmed that the facility does not have a borrowing protocol. The DON stated that the process was for obtaining the resident's medications was to remove the sticker and place it on paper to fax to the pharmacy, call the physician and follow through with the orders obtained. The DON mentioned that Pantoprazole was not one of the medications stored in the backup box. The DON also confirmed that medications were not borrowed from other residents because, That's somebody else's medication, they paid for it. On 03/05/21 at 09:23 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) and DON in the survey team's presence. The LNHA stated that nurses should not be borrowing medications from any resident. The LNHA and DON confirmed that the facility did not have a borrowing protocol, and the DON then added that she looked on the backup box medication list and noticed that Pantoprazole was included. A review of the LPN #2 Orientation Checklist provided by the DON revealed a performance skill that consisted of Medication Administration: Medication Pass dated 1/5/21. A review of the facility's form titled, Patient Medication Usage Form read under procedures: 1. Remove medication from Back-up Box 2. Complete replacement request form indicate quantity used 3. Fax completed form to the pharmacy The form revealed under the section labeled Non-Antibiotics, Pantoprazole 40 MG Tab ([MEDICATION NAME]) was listed as a medication in the backup box. A review of the Consultant Pharmacists guidance provided by the facility, indicated under Administration of Medication - State Regulation (Pour, Pass, and Sign); under number 3, it read, medication not in the medication cart must be obtained from the backup pharmacy/alternate source. Not available is not acceptable. Never borrow. On 3/8/21 at 1:35 PM, the surveyor interviewed the CP, who confirmed that medications should not be borrowed from another Residents medications. NJAC 8:39 - 29.2

Based on observation, interview, and record review, it was determined that the facility failed to ensure appetizing and palatable temperature of food for a resident who required assistance for eating. This deficient practice was observed for 1 of 2 residents reviewed for feeding assistance (Resident #70), and was evidenced by the following: On 3/1/21 at 12:40 PM, the surveyor observed Resident #70 lying in bed. The resident refused to speak with the surveyor. The surveyor reviewed the medical record for Resident #70. A review of the Admission Record reflected that the resident was admitted to the facility in December of 2016 with [DIAGNOSES REDACTED]. A review of the most recent quarterly Minimum Data Set (MDS), a tool used to facilitate the management of care dated 1/18/21, indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated that the resident had a moderately impaired cognition. A further review of the MDS Section G. Functional Status reflected that the resident required extensive assistance of one person physical assistance for eating. A review of the resident's individualized person centered Care Plan had a focus area initiated on 1/8/19 and revised date of 2/4/21 that read: I require assistance/potential to restore function for eating related to difficulty chewing/swallowing and disease process. Interventions included; to check for food remaining in mouth after swallowing; cue to clear throat if voice is wet or gurgling; position upright for meals; and refer to the Therapy Plan of Treatment in the medical record for more detail. On 3/3/21 at 8:20 AM, the surveyor observed the meal truck arrive to B Wing. Resident #70's breakfast tray was observed on that truck. At 8:33 AM, the surveyor observed the Assistant Director of Nursing (ADON) deliver Resident #70 roommate's breakfast tray. At 8:48 AM, the surveyor observed Resident #70 in bed with no breakfast tray. At this time, the surveyor interviewed the resident who confirmed he/she was hungry. At 8:50 AM, the surveyor interviewed the resident's Licensed Practical Nurse (LPN) who stated that the resident required assistance with feeding so he/she received their meal tray when someone was available to assist and feed them. The LPN then proceeded to retrieve the resident's breakfast tray from the truck and fed the resident. On 3/3/21 at 12:59 PM, the surveyor observed the meal truck arrive to B Wing. Resident #70's lunch tray was observed on that truck. At 1:11 PM, the surveyor observed Resident #70's roommate in their room eating lunch. The surveyor observed that Resident #70 had no lunch tray. At 1:37 PM, the surveyor observed Resident #70's lunch tray still on the meal truck. At this time, the surveyor observed that the resident was still not eating lunch. At 1:46 PM, the Staff Coordinator/Certified Nursing Aide (CNA) removed the resident's lunch tray from the meal truck and placed it on the resident's dresser. The Staff Coordinator/CNA then proceeded out of the room to obtain an over-bed table to feed the resident. At 1:56 PM, the surveyor observed the resident served soup by the Staff Coordinator/CNA. The resident stated that he/she disliked the soup. Upon questioning, the resident confirmed that the soup was cold and requested a peanut butter and jelly sandwich. On 3/8/21 at 1:25 PM, the surveyor interviewed the Director of Nursing (DON) in the presence of the Licensed Nursing Home Administrator (LNHA) and ADON, who stated that when meal trays arrived to the unit, both the nurses and aides delivered the trays to the residents. Residents who were able to feed with minimal to no assistance were served first, followed by residents who required assistance to feed were then fed. The DON stated that a resident's meal tray should not be sitting on the meal cart for almost an hour and that the longer the food sat, the temperature decreased. The DON stated that cold food was not appetizing or appealing. A review of the facility's Nutritional Services policy dated 3/14/14 and revised date 3/9/15, included that the Dietary Department will develop an order of service for all meals which best suits the needs of the residents. The schedule will be followed. N.J.A.C. 8:39-17.4(a)2

Complaint # NJ 4 Based on observations, interviews, and review of medical records on 12/19/2019 and 12/23/2019, it was determined that the facility staff failed to follow appropriate infection control guidelines for 1 of 6 sampled residents (Resident #5) and failed to follow the Facility Policy titled Infection Control/Urinary Catheters. This deficient practice was evidenced by the following: 1. According to the Admission Record (AR), Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), an assessment tool dated 9/20/2019, Resident #5 had a Brief Interview for Mental Status (BIMS) score of 13/15, indicating the resident was cognitively intact. The MDS also indicated that Resident #5 required extensive assistance for Activities of Daily Living (ADLs). According to the Physician's Order Form with a review date of 12/2019, Resident #5 Foley Catheter orders included the following: 8/28/2019, Foley Catheter Care every shift and attach Foley bag and note urine clarity every shift. During a tour of D wing accompanied by the Unit Manager (UM) on 12/19/2019 at 10:17 a.m., a wash basin was observed on the sink in the resident's bathroom which contained mouthwash, toothpaste, and a comb. Observed sitting in the wash basin was also a Foley drainage bag with urine in the bag and no cap was on the end of the tubing. During an interview on 12/19/2019 at 10:20 a.m., the UM stated: It's disgusting that the Foley bag was put in the wash basin. During an interview on 12/19/2019 at 10:22 a.m., the Certified Nursing Assistant (CNA#1) stated; She was coming back to clean the urine bag with soap and water, and she was aware that placing the urine bag in the wash basin was an infection control issue. During an interview on 12/19/2019 at 2:34 p.m., the Director of Nursing (DON) reported that the CNA should have rinsed out the urine bag or thrown it out immediately. The DON also reported the Facility Policy states To rinse them out and change them weekly. Review of the Facility Policy titled Infection Control, Urinary Catheters dated 5/1/2019, under Policy revealed the following: To provide guidance in the preventive measures for controlling common infections for residents with a urinary catheter as part of the overall infection control program. The facility is committed to providing a safe and healthy environment for residents and to minimize or prevent the spread of infections. In addition, under Procedure; #21; was the following: Use aseptic technique when disconnecting, reconnecting, and storing bedside drainage/leg bags. Under General Information: Residents requiring a urinary catheter are a higher risk for infection.

Complaint #: NJ 1 Based on interviews and review of the medical record and other facility documentation it was determined that the facility failed to follow physician orders [REDACTED]. (Resident #3). This deficient practice is evidenced by the following; 1. According to the Admission Record Resident #3 was admitted to the facility in 1/2019 with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), as assessment tool, dated 4/29/2019 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 5 which indicated severe cognitive impairment and needed assistance with all activities of daily living. Review of a Care Plan (CP), initiated 2/20/2019, revealed the resident was at risk for adverse effects related to (r/t) the use of antipsychotic medication, [MEDICATION NAME]. Interventions included but were not limited to Med Options Evaluation of current medications. A 2/20/2019 Physician order [REDACTED]. tablet (tab.) to be administered daily at 9 am and [MEDICATION NAME] 50 mg. tab., to be administered daily in the evening. Review of the 2/2019 Medication Administration Record [REDACTED] Review of a Med Options Consult, signed by an Advanced Practice Nurse (APN) and dated 2/26/2019, revealed to discontinue (d/c) [MEDICATION NAME] 25 milligrams (mg.) by mouth in am for 3 days and evaluate behavior, mood and alertness. If it improves, d/c [MEDICATION NAME] and if not, restart. Review of a Nursing/Clinical Progress Note (PN) dated 2/26/2019 at 9:25 pm revealed; Telephone Order Discontinue [MEDICATION NAME] 25 MG (milligrams) PO (by mouth) in the [NAME]M. for 3 days and re-evaluate behavior. If mood/behavior improves discontinue [MEDICATION NAME], if not effective restart [MEDICATION NAME] in the [NAME]M. A POS, dated 2/26/2019, revealed a telephone order (TO) which indicated to Discontinue [MEDICATION NAME] 25 mg (milligrams) po (by mouth) for 3 days and evaluate behavior. If mood/alertness improves d/c (discontinue) [MEDICATION NAME], if not effective restart [MEDICATION NAME] 25 mg. in am. The POS indicated a 24 hour (hr.) nursing chart check of physician orders [REDACTED].#1. Review of the 2/2019 MAR indicated [REDACTED]. Review of the 2/2019 MAR indicated [REDACTED]. During an interview with the surveyor on 9/30/2019 at approximately 12:15 pm, the Director of Nursing (DON) confirmed that the PO should have been followed and the [MEDICATION NAME] should have been held on 2/27/2019. NJAC: 8:39-27.1

Based on observation, interview, and record review, it was determined that the facility failed to: a.) develop individualized, comprehensive care plans to address target behaviors, the use of a soft cervical collar, and a contracture, and b.) ensure a goal was measurable. This deficient practice was identified for 6 of 27 residents reviewed, (Resident #27, #61, #62, #64, #90 and #93), and was evidenced by the following: 1. On [DATE] at 10:30 AM, the surveyor observed Resident #64 in the physical therapy room with a cervical soft collar around his/her neck. On [DATE] at 12:17 PM, the surveyor observed the resident at a table eating lunch with the cervical soft neck collar on. The surveyor attempted to interview the resident. The resident stated that lunch was good and continued to speak to another resident at the table regarding drinking milk. The resident was unable to answer any further questions. On [DATE] at 09:39 AM, the surveyor interviewed the Certified Nursing Aide (CNA). The CNA stated she was familiar with the resident since admission and has had a neck collar all the time except for when he/she received a shower. The CNA stated that the resident can make his/her needs known, but was very forgetful and can become very confused. The CNA added that the resident did have behaviors of getting upset and nervous and could yell at staff when he/she exhibited confusion. The CNA also stated that she felt the resident was more calm in the morning and the behaviors occurred more in the afternoon. The CNA added that she would tell the nurse if she was unable to redirect the resident when he/she became upset. On [DATE] at 09:41 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that the resident was going to be discharged from the facility soon. The LPN stated that during the resident's stay in the facility he/she had periods of restlessness such as self-propelling to the point of exhaustion, following the nurse while pushing the medication cart and grabbing the medication cart. She added that the resident would make repetitive statements and become very anxious and nervous and had periods of not being able to sleep, remaining awake all night. In addition, the LPN stated that there were times when the resident would not be able to be redirected after several interventions and she would have to administer an as needed (PRN) medication ([MEDICATION NAME]) to help the resident calm down. The LPN stated that the ICCP was in the computer and there was a form in the narcotic drug book to monitor behaviors. She added that both the Medication Administration Record [REDACTED]. The surveyor reviewed the medical record for Resident #64. A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated [DATE] reflected that the resident was admitted to the facility on [DATE] and had active [DIAGNOSES REDACTED]. The assessment included that the resident had a brief interview for mental status (BIMS) score of 5 out of 15, reflecting a cognitive impairment. The MDS also reflected that the resident was on antipsychotic medication(s) for the last seven out of seven days, and exhibited no behaviors since admission to the facility. A review of the (MONTH) (YEAR) physician's orders [REDACTED]. A review of the PO indicated an order dated [DATE] to discontinue the Aspen collar (device used to immobilize the neck) and to apply a soft collar at all times. The order included that it may be removed for hygiene and showers. Further review of the PO indicated orders dated [DATE] for [MEDICAL CONDITION] drugs including, [MEDICATION NAME] 50 mg one tablet by mouth every 12 hours and [MEDICATION NAME] 5 mg one tablet by mouth at bedtime, and [MEDICATION NAME] 0.5 mg by mouth every 8 hours PRN anxiety. A review of the (MONTH) (YEAR) Psychoactive Drug Flowsheet (form used to monitor and document target behaviors for specific drugs) reflected that a target behavior of repetitive anxious complaints was being monitored. The form did not specify what those anxious complaints were in relation to. A review of the Psychiatric consult dated [DATE] indicated a medication management assessment which included target symptoms of anxiety, apprehension, behavioral disturbances, changes in mood, recent changes in sleep. A review of the resident's individualized Comprehensive Care Plan (ICCP) did not address the resident's anxiety or behaviors associated with dementia, target behaviors and the use of the soft cervical collar secondary to the resident's recent fracture. On [DATE] at 10:16 AM, the survey team met with the Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON). The DON stated that the ICCP was completed by nursing and initiated based on a review by the interdisciplinary team. The DON acknowledged that the soft cervical collar and the target behaviors of anxiety and behaviors should be included on the ICCP. 2. On [DATE] 09:50 AM, the surveyor observed Resident #27 in a wheelchair, leaning towards the right side with his/her eyes closed. The resident's right hand was exposed and appeared to be tightly gripped with the wrist flexed toward the resident's torso. The resident's hand was resting on his/her lap. On [DATE] at 12:18 PM, the surveyor observed the resident at lunch being fed by the Licensed Practical Nurse (LPN). The resident's right hand was exposed and appeared tightly gripped with the wrist flexed toward the resident's torso, just as the surveyor had observed on [DATE]. On [DATE] at 09:27 AM, the surveyor observed the resident lying in bed on a scoop mattress. The resident was awake, alert and smiling. The surveyor observed the resident's right and left hand resting over the bed sheets in his/her lap and both appeared tightly gripped. The resident's wrists were flexed toward his/her torso. The surveyor observed one blue hand splint on the resident's bedside table. The surveyor attempted to interview the resident. The resident stated that he/she can write and feed himself/herself with either hand. At that time, the resident started inaccurately repeating statements that he/she knew the surveyor on a personal level. The surveyor reviewed the medical record for Resident #27. A review of the Admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility [DATE] with [DIAGNOSES REDACTED]. A review of the admission MDS dated [DATE] reflected BIMS score of 3 out of 15 which reflected the resident had a cognitive impairment. It further reflected the resident had functional limitations to both upper extremities. A review of the physician's orders [REDACTED]. A review of the physician's notes dated [DATE], reflected the resident had a right-hand splint. A review of the residents individualized, comprehensive care plan dated [DATE], reflected the resident had a left-hand contracture. The care plan did not reflect a right-hand contracture. On [DATE] at 09:42 AM, the surveyor interviewed the residents Certified Nursing Aide (CNA). The CNA stated that both of the resident's hands were contracted. On [DATE] at 10:39 AM, the surveyor interviewed the MDS Coordinator. The surveyor and the MDS Coordinator reviewed the resident's admission MDS dated [DATE] together as well as an OT evaluation dated [DATE]. She stated that she completed the section that indicated the resident had limitations to both upper extremities, but could not speak to the specific location. After reviewing the OT evaluation in the presence of the surveyor, the MDS Coordinator acknowledged the resident had contractures to both hands. She further stated that the resident's care plan does not speak to the right hand contracture and should be included in the care plan that identified the resident required assistance with activities of daily living. On [DATE] at 11:03 AM, the surveyor interviewed the resident's LPN, who stated that both of the resident's hands were contracted. On [DATE] at 11:26 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM). The RN/UM confirmed that both of the resident's hands were contracted. The surveyor and the RN/UM reviewed the resident's individualized care plan together. The RN/UM provided a copy of a resolved care plan but was unable to provide documented evidence of a care plan for the right-hand contracture. On [DATE] at 11:41 AM, the surveyor interviewed the Director of Rehabilitation/Occupational Therapist (OT). The Director of Rehabilitation stated that the resident was assessed on [DATE] for hand contractures. He confirmed that both of the resident's hands were contracted. He stated that he does not document in the resident care plan, but that the nurses do it. On [DATE] at 12:46 PM, during a meeting with the survey team and facility administrative staff, the Director of Nursing (DON) provided the surveyor with a communication form from nursing to therapy dated [DATE], which reflected the resident was observed with right and left-hand contractures. The DON also provided the surveyor with OT treatments notes dated [DATE], [DATE], [DATE] and [DATE], which reflected the resident received treatment for [REDACTED]. The DON acknowledged the care plan should include both contractures. 3. On [DATE] at approximately 12:18 PM, the surveyor observed Resident #62 in the main dining room at lunch. The resident was in a wheelchair seated at a table and was being fed by a staff member. The surveyor observed the resident crying. The staff member attempted to console the resident and provided tissues to dry his/her tears. The surveyor reviewed the medical record for Resident #62. A review of the physician's orders [REDACTED]. A review of the resident's annual MDS dated [DATE], reflected a BIMS score of 6 out of 15, which indicated that the resident had a cognitive impairment. A review of an Activity note dated [DATE], reflected that the resident cried on occasion and had recently cried stating his/her mother had passed away. On [DATE] at 10:20 AM, the surveyor interviewed the Certified Nursing Aide (CAN) who stated that she had observed the resident crying. She stated it happens occasionally, every couple of weeks. On [DATE] at 10:29 AM, the surveyor interviewed an Activity Aide. She stated that she had observed the resident with episodes of crying. She stated the episodes were seldom and usually occur during mealtime, and not during activity programs. She stated that the last episode she observed was approximately two weeks ago during the breakfast meal in the main dining room. She stated that the resident repeated the words, my son, my daughter. On [DATE] at 11:16 AM, the surveyor interviewed the Director of Activities. She stated that the resident had episodes of crying. She stated it happens about once a month and more so at meal times than at activities. She stated that when the resident had cried, he/she verbalized that he/she missed his/her mother. The Director of Activities stated she thought her observations were documented in her notes but not on the resident's care plan. A review of the resident's individualized, comprehensive care plan initiated [DATE] did not address the resident's observed, documented, and reported episodic crying during meals. On [DATE] at 10:57 AM, during a meeting with the survey team and facility administrative staff, the DON acknowledged that the resident exhibited crying on occasion and that the care plan did not reflect the resident's behavior of episodic crying. She confirmed the care plan should have included this behavior. 4. On [DATE] at 9:02 AM, the surveyor observed the Registered Nurse (RN) standing in front of her medication cart in front of the dayroom. The RN was heard asking where Resident #93 was. The surveyor overheard the Licensed Practical Nurse/Unit Manager (LPN/UM) state that the resident was just in the dayroom. The surveyor then observed a CNA enter B-Wing unit from C-Wing wheeling Resident #93 down the hall. The CNA informed the staff that the resident had self-propelled to C-Wing. On [DATE] at 8:55 AM, the surveyor observed Resident #93 in the hallway directly in front of the dayroom. The resident was yelling and screaming to him/her-self. The resident was stating I'm leaving. The surveyor observed facility staff intervening and was able to redirect the resident to his/her room to be toileted. On [DATE] at 9:15 AM, the surveyor reviewed the medical record for Resident #93. A review of the resident's Face Sheet reflected that the resident was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of the quarterly MDS dated [DATE], reflected that the resident had a brief interview for mental status (BIMS) score of 5 out of 15, which indicated that the resident had a cognitive impairment. A review of the Physician order [REDACTED]. A review of the resident's individualized Care Plan (CP) initiated on [DATE] and revised [DATE] included a focus for the [DIAGNOSES REDACTED]. The intervention included to orient the resident to placement of foods on the plate and/or tray. A review of the CP focus initiated [DATE] and revised [DATE] indicated that the resident had a behavior of verbal, physical, agitation, aggression, yelling, banging tables, and restlessness related to cognitive impairment and anxiety. Interventions included to administer medication per physician orders, approach slowly and slightly to the side, be aware of patient's personal space, provide diversional activities, remove from public area when behavior is disruptive and/or unacceptable, and talk in a low pitch calm voice to decrease and/or eliminate undesired behavior. On [DATE] at 11:19 AM, the surveyor observed Resident #93 in the dayroom. The resident was yelling and appeared agitated. The resident expressed that they are all dummies. The surveyor observed staff was present. The resident's son/daughter redirected the resident to his/her room. At 11:40 AM, the surveyor interviewed the resident's son/daughter. He/she informed the surveyor that the resident was transferred to the facility in (MONTH) from another facility. The representative indicated that the resident was not cognitively all there at this point. He/she believed that the resident was unaware of where he/she was. He/she also believed the resident currently was unaware who he/she was. He/she stated that the resident had never attempted to leave/elope from the facility. On [DATE] at 9:22 AM, Resident #93's CNA informed the surveyor that the resident was confused and screamed when he/she was agitated. The resident will say he/she had a doctor's appointment and had to leave. The CNA stated that the resident will make it to the entrance of the dayroom before being redirected by staff. The CNA denied being aware of the resident ever leaving the unit. At 9:42 AM, the RN informed the surveyor that the resident was anxious at times. The RN believed that was due to the resident could not see well because he/she was legally blind. The resident verbalized that he/she could not see because the bird ate my eye. The RN stated that the resident wanders around the unit but does not leave the unit. The RN further stated that the resident had not voiced the desire to leave the facility. The RN added that the resident had gone by his/her-self to C-Wing in the past, but staff usually will bring him/her back. The RN was unsure how many times this happened exactly, but stated it occurred a handful of times. The RN stated that she would not classify the resident as a wanderer because he/she does not voice the desire to elope. The RN believed the resident wanders because of his/her vision and becomes confused looking for his/her room. The surveyor continued to review the medical record. A review of the resident's Interdisciplinary Progress Notes from [DATE] to present reflected the resident was confused. There was no documented evidence that the resident had wandered looking for his/her room through the hallways, or off the unit as indicated by the RN. On [DATE] at 12:09 PM, the UM informed the surveyor that she oversaw the development and updating of CP's. She stated that CP's are specific and individualized to each resident. The care plan would include any preference and behaviors including wandering. The UM stated she was unsure if Resident #93 was a wanderer and would need to follow-up with staff. On [DATE] at 10:47 AM, the Assistant Director of Nursing (ADON) informed the surveyor that she was familiar with Resident #93. If the resident stated that he/she was leaving, that meant that he/she wanted to be brought back to his/her room. The ADON acknowledged that behavior was specific to the resident and should addressed in the residents individualized plan of care. At 10:54 AM, the Administrator acknowledged in the presence of the survey team, that the facility needed to address the resident's CP's being specific and individualized. At 12:47 PM, the DON informed the surveyor that Resident #93's CP needed to be updated to address the resident's behavior. 5. On [DATE] at 11:00 AM, the surveyor attempted to observe Resident #61, but the resident was unavailable. The surveyor reviewed the medical record for Resident #61. A review of the Transfer/Discharge Report face sheet (an admission summary), reflected that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the admission MDS dated [DATE], reflected that the resident had a brief interview for mental status (BIMS) score of 13 out of 15, indicating an intact cognition with some forgetfulness. The assessment further indicated that the resident had no noted behaviors in the last seven days and received medications on a daily basis in the last seven days including an antipsychotic, an antidepressant, and an antianxiety medication. A review of the Physician order [REDACTED]. A review of a subsequent handwritten physician's orders [REDACTED]. The PO indicated to administer Klonopin 0.25 mg by mouth daily. A review of the Medication Administration Record [REDACTED]. A review of the Psychoactive Drug Flow Sheet (a sheet used for monitoring target behaviors) for (MONTH) (YEAR) reflected that the resident was on Klonopin for anxiety. The flow sheet had a list of pre-printed target behaviors in which staff could select from. The flow sheet reflected an x marking next to the target behavior for Repetitive Anxious complaints/concerns (non-health related) -e.g. persistently seeks attention/re-assurance regarding schedules, meals, laundry, relationship issues. The flow sheet for (MONTH) was blank to indicate the resident did not exhibit an episodic episode that month. A review of the resident's individualized care plan dated [DATE] reflected that the resident was at risk for side effects related to the use of psychoactive medications. The goal included, I will show improvement in mood/behavior through the next review date. Interventions were not initiated until [DATE] and included to provide education to risk and benefits of medications as needed, Psychiatrist consult and follow-up as needed, reduce environmental noise and distractions to facilitate sleep. The care plan did not address the resident's target behaviors of anxiety and/or how the resident presents when he/she was experiencing an anxious episode, potential triggers and/or evidence of a measurable goal to reduce target symptoms. On [DATE] at 11:27 AM, the surveyor interviewed the Certified Nursing Aide (CNA) who stated that she had worked as a CNA at the facility for approximately one year, and was a per-diem staff member. The CNA confirmed she had worked with Resident #61 since the resident had switched from the subacute unit to the long-term care unit a few weeks ago. She stated that the resident was alert and oriented to person, place and time with forgetfulness. She stated that she assisted the resident with daily care in the morning and that he/she does not exhibit behaviors or signs of anxiety. She stated that the resident was quiet, but added that he/she was a stickler about flossing and dental hygiene. The CNA also explained that the resident also questioned about his/her clothing and making a decision about what to wear daily. She added that the resident gets fixated about whether a shirt will fit and the CNA stated that she had to explain to the resident that the shirt fits him/her. She stated that it did not cause distress to the resident when deciding on what to wear and/or performing his/her dental hygiene. At 11:33 AM, the surveyor interviewed the resident's full-time Registered Nurse (RN). The RN stated that the resident was not oriented, and had moments of confusion. She stated that the resident was anxious all the time especially about his/her bowel medication regimen. She added that the resident gets focused on his/her bowel movements, and that it stresses him/her out about whether or not to take the medication. She stated that it does not distress the resident because once he/she makes the decision to take it after convincing he/she would be fine. The RN added that the resident had a reduction in the dose of the anti-anxiety medication Klonopin yesterday as the resident had not exhibited distressing target behaviors. The surveyor asked the RN who was responsible for developing the resident's individualized care plan. The RN stated that it was mostly the responsibility of the Registered Nurse/Unit Manager (RN/UM). The RN was unable to speak to the resident's care plan regarding his/her target behaviors. She confirmed that the target behaviors get written on the Psychoactive Drug Flow Sheet and that was what she goes by. At 11:45 AM, the surveyor interviewed the RN/UM. The RN/UM stated that Resident #61 was forgetful, confused and always had to be re-directed by staff. The RN/UM confirmed that the resident was redirected easily. The RN/UM confirmed that the resident did not have any unusual behaviors, and that if anything redirection was needed just due to confusion. The surveyor and RN/UM reviewed the resident's medications together and the RN/UM confirmed the resident was taking Klonopin for anxiety. The RN/UM stated that the resident possibly exhibited anxiety related to care and hygiene as he/she was very into that possibly triggering anxiety episodes, but confirmed the resident was not in distress. She stated that the Physician had reduced the Klonopin medication when the family had made the request to reduce the dose. The RN/UM explained that the resident's family visited daily, but she was unable to speak to the resident's history of anxiety and/or how he/she presented when anxious and/or why the resident was on the Klonopin. She stated she would have to ask the family. At that time, the surveyor and RN/UM reviewed the resident's individualized care plan together. The RN/UM confirmed she was responsible for the resident care plans. The RN/UM acknowledged that the target behaviors were not included in the resident's plan of care because she did not know what they were. She stated that the care plan was initiated when he/she was on another unit. She acknowledged that the Psychoactive Drug Flow Sheet with the target behavior of repetitive anxious complaints/concerns should be included in the resident's care plan, and his/her potential triggers to anxiety. The surveyor asked about the care plan goal to, I will show improvement in mood/behavior through the next review date. The surveyor asked how she would measure improvement. The RN/UM confirmed she could not quantify improvement and confirmed that the goal was not appropriate, since the resident wasn't exhibiting episodes when he/she was unable to be re-directed. On the same day, [DATE] at 12:23 PM, the surveyor observed Resident #61 sitting in the main dining room in a wheelchair self-feeding and finishing a chopped up lunch and a yogurt. The resident appeared wide-eyed, but calm. The surveyor attempted to speak to the resident, and the resident stated he/she was ok. The resident exhibited non-verbal signs that he/she did not want to be disturbed at that time. At 12:29 PM, the surveyor attempted to conduct a phone interview with the resident's family representative, but the surveyor left a voicemail as the representative was unavailable. On [DATE] at 10:15 AM, the surveyor interviewed the Director of Nursing (DON) in the presence of the survey team. The DON confirmed that the resident's care plan had no appropriate/measurable goal and confirmed that the word improvement did not promote a quantifiably measurable goal. The DON stated that the resident's spouse had recently expired, and that the resident had a history of [REDACTED]. She stated that the resident had a history of [REDACTED]. The DON confirmed that this information should have been part of the resident's individualized care plan. She stated the reason it was not added was because the resident had not exhibited the symptoms at the facility, but confirmed the admitting nurse, who was responsible for creating the care plan should have attempted to obtain the behavioral history to include in the care plan, since the resident was on the antianxiety medication, Klonopin. 6. On [DATE] at 10:00 AM, the surveyor observed Resident #90 sitting upright on the edge of the bed. The resident appeared well groomed and well dressed. The surveyor interviewed the resident who was awake and alert. The resident was soft spoken and calm. The resident stated that he/she had lived at the facility for about two weeks and participated in physical therapy at the facility. The resident further stated that if he/she ever needed help, the staff would come and help him/her. On [DATE] at 8:46 AM, the surveyor observed the resident in his/her room. The resident was well dressed and eating breakfast. The resident calmly explained to the surveyor that he/she planned on walking in physical therapy later in the day. The surveyor reviewed the medical records for Resident #90. A review of the resident's face sheet reflected that the resident was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of the resident's admission MDS dated [DATE], indicated the resident had a BIMS score of 13 out of 15 which reflected the resident was alert and oriented with some forgetfulness. The MDS assessment further indicated that the resident did not exhibit behaviors since entry to the facility. A review of the (MONTH) (YEAR) physician's orders [REDACTED]. The (MONTH) (YEAR) form further indicated the resident had a PO dated [DATE], for the antipsychotic medication, [MEDICATION NAME] 1 mg orally at bedtime. A review of the Medication Management Assessment (MMA) completed by the Psychiatric Nurse Practitioner dated [DATE], indicated the resident had [DIAGNOSES REDACTED]. The MMA further indicated that the resident was receiving the [MEDICAL CONDITION] medication for target behaviors of behavioral disturbances, changes in mood, paranoia or delusions, and preoccupations. A review of the (MONTH) (YEAR) Psychoactive Drug Sheet (PDS) indicated that the resident was on the antidepressant medication, [MEDICATION NAME] for target behaviors of reduced social interaction and withdrawal from activities of interest. A further review of the (MONTH) (YEAR) PDS indicated that the resident was on the antipsychotic medication, [MEDICATION NAME] for target behaviors of resisting care. A review of the resident's Interdisciplinary Comprehensive Care Plan (ICCP) revised on [DATE] revealed a focused area that the resident was on the [MEDICAL CONDITION] medication [MEDICATION NAME] related to [MEDICAL CONDITION] disorder. The goal of the [MEDICAL CONDITION] medication ICCP indicated that the resident would remain free of [MEDICAL CONDITION] drug related complications through the review date. The interventions of the [MEDICAL CONDITION] medication ICCP included to administer the medications as ordered by the physician, monitor for side effects, adverse effects, and effectiveness. Further interventions included to consult with the pharmacy and doctor for a dose reduction when clinically appropriate. The [MEDICAL CONDITION] medication ICCP did not reflect the target behaviors of the resident. A further review of the resident's ICCP revised on [DATE] revealed a focus area that the resident was on the antidepressant medication [MEDICATION NAME] related to depression. The goal of the antidepressant ICCP was that the resident would remain free from discomfort or adverse reactions related to antidepressant therapy through the review date. The interventions of the antidepressant ICCP included to administer the medication as ordered, to document side effects and effectiveness of the medication. Further interventions included to educate the resident and family about risk and side effects of the antidepressant medication. The antidepressant medication ICCP did not reflect the target behaviors of the resident for the clinical need of the antidepressant medication. On [DATE] at 11:01 AM, the surveyor interviewed the resident's CNA. The CNA stated that the resident at times had a behavior of refusing care in the morning, because the resident preferred to shower at night time. The CNA further stated that when the resident refused care she would tell the nurse. On [DATE] at 11:10 AM, the surveyor interviewed the resident's Registered Nurse (RN). The RN stated that the resident was, quiet and pleasant. The RN stated that the resident prefers to stay in his/her room and engage in independent activities. The RN further stated that she did not know the resident to have behaviors when she cared for the resident and the resident never refused medications. On [DATE] at 9:37 AM, the surveyor interviewed the Licensed P (TRUNCATED)

Based on observation, interview, and record review, it was determined that the facility failed to document episodic verbal behaviors for a resident on psychoactive medications. This deficient practice was identified for 1 of 9 residents reviewed for psychoactive medication use (Resident #93) and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states, The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states, The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 08/24/18 at 8:55 AM, the surveyor observed Resident #93 in the hallway directly in front of the dayroom. The resident was yelling and screaming to him/her-self. The resident was heard stating I'm leaving. The surveyor observed facility staff intervening and was able to redirect the resident to his/her room to be toileted. On 08/27/18 at 9:15 AM, the surveyor reviewed the medical record for Resident #93. A review of the resident's Face Sheet (an admission summary) reflected that the resident was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 07/29/18 reflected that the resident had a brief interview for mental status (BIMS) score of 5 out of 15, which indicated the resident had a cognitive impairment. A review of the Physician order [REDACTED]. There was an additional physician order [REDACTED]. A review of the resident's individualized Care Plan (CP) initiated 06/27/18 and revised 7/27/18 indicated that the resident had a behavior of verbal, physical, agitation, aggression, yelling, banging tables, and restlessness related to cognitive impairment and anxiety. Interventions included to administer medication per physician orders, approach slowly and slightly to the side, be aware of patient's personal space, provide diversional activities, remove from public area when behavior is disruptive and/or unacceptable, and talk in a low pitch calm voice to decrease and/or eliminate undesired behavior. On 08/27/18 at 11:19 AM, the surveyor observed Resident #93 in the dayroom. The resident was yelling and appeared agitated. The resident expressed that they are all dummies. The surveyor observed staff were present. The resident's son/daughter redirected the resident to his/her room. At 11:40 AM, the surveyor interviewed the resident's son/daughter. He/she informed the surveyor that the resident was transferred to the facility in (MONTH) from another facility. The family representative added that the resident was not cognitively all there at this point. He/she believed that the resident was unaware of where he/she was. He/she also believed the resident currently was unaware who he/she was. On 08/28/18 at 9:22 AM, Resident #93's Certified Nursing Assistant (CNA) informed the surveyor that the resident was confused and screamed when he/she was agitated. At 9:42 AM, Resident #93's Registered Nurse (RN) informed the surveyor that the resident was anxious at times. The RN believed that was due to the resident could not see well because he/she was legally blind. The resident verbalized that he/she could not see because the bird ate my eye. The RN also stated that the resident was hard of hearing and could be loud at times. The surveyor reviewed the resident's Interdisciplinary Progress Notes (IDPN). There was no evidence of a nursing note to reflect the observed verbal outbursts that the surveyor observed on 08/24/18 and 08/27/18. The surveyor reviewed the resident's Psychoactive Drug Flow Sheet (used for the documentation/monitoring of target behaviors) for (MONTH) (YEAR). The sheet indicated that the resident was monitored for behaviors associated with the anti-anxiety medications. The target behaviors were repetitive verbalizations example calling out and repetitive physical movements. The sheet was blank for episodic behaviors for the month of (MONTH) (YEAR), reflecting that the resident had not expressed any behaviors. At 9:57 AM, the surveyor reviewed the (MONTH) (YEAR) Psychoactive Drug Flow Sheet with the RN. The RN stated that she was responsible during her shift to document any behaviors on that sheet. She explained that the nurse documented episodically on that sheet only if there was a behavior occurrence. The RN stated that the resident had episodes that month, but had not documented it because she was able to calm the resident down and redirect him/her. At 10:18 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM). The LPN/UM informed the surveyor that the nurse would mark the Psychoactive Drug Flow Sheet episodically. She stated that Resident #93 needed to be redirected by offering juice, snacks, or being brought back to his/her room. The LPN/UM stated that if the resident needed to be redirected, then the nurse should mark the episode on the flow sheet. The LPN/UM stated it was important to fill the sheet out because she prepared the monthly summary report of number of episodic behaviors. This indicated if the medication was effective or not. The nurse also communicated this information to the Psychiatrist. At 1:33 PM, the surveyor reviewed the facility's Behavior Management Program Policy dated (MONTH) (YEAR). The policy indicated that identified behaviors should be evaluated for frequency, duration and intensity for a pattern by the documentation on the Medication Administration Record [REDACTED] At 01:42 PM, the Director of Nursing (DON) informed the surveyors that the facility charted by exception on behaviors. The facility prepared a monthly report of episodic behaviors. On 08/29/18 at 10:47 AM, the surveyor interviewed the DON in the presence of the survey team. The DON confirmed that the Psychoactive Drug Flow Sheet had not reflected the behaviors observed by the surveyor on 08/24/18 and 08/27/18. The DON stated that she needed to investigate if the nurse documented these episodes anywhere else. At 12:47 PM, the DON confirmed that there was no documentation that reflected the verbal behaviors observed by the surveyor on 08/24/18 and 08/27/18. NJAC 8:39-11.2 (b)

Based of observation, interview, and record review, it was determined that the facility failed to ensure: a.) a controlled drug was stored under double-lock, and b.) the same controlled drug was dispensed in accordance with professional standards of practice. This deficient practice was identified for Resident #61 when 1 of 3 medication carts were inspected (High Side, B-Unit), and was evidenced by the following: On 08/29/18 at 9:20 AM, the surveyor inspected the high-side medication cart on the B-Unit in the presence of the Registered Nurse (RN). The RN unlocked the medication cart and the surveyor opened the top drawer and observed a half tablet pill in a clear, plastic, unlabeled medication cup. The surveyor asked the RN what the pill was and why it was stored in the top drawer of the medication cart. The RN stated that the pill was the controlled drug, Klonopin (a narcotic used to treat anxiety) and that she, forgot to give it to Resident #61 when she administered the resident's 9:00 AM medications because something had distracted her. The RN further stated that the medication was not appropriately stored and under a double-lock system and should not have been left in the top drawer of the medication cart. The surveyor then reviewed the Individual Patient's Controlled Drug Record (IPCDR) for Resident #61 in the presence of the RN. The IPCDR indicated that the RN signed for the dispensing of the narcotic, Klonopin at 9:00 AM. At that time, the RN unlocked the controlled drug box in the medication cart, and the surveyor and RN reviewed the Klonopin narcotic count together. The count in the IPCDR matched what was on the un-dispensed, Klonopin inventory for Resident #61. The surveyor then observed the RN stop a staff member who was pushing Resident #61 in his/her wheelchair. The RN stated that she had to administer the resident's medication. The surveyor then observed the RN bring Resident #61 into his/her room and she administered the Klonopin that the surveyor observed in the top drawer of the medication cart to the resident. On 08/29/18 at 9:55 AM, the surveyor conducted a follow-up interview with the RN. The RN stated that she signed for the medication Klonopin on the Medication Administration Record [REDACTED]. The RN further stated that any medication ordered was supposed to be signed for after it was administered to the resident and not before. A review of the (MONTH) (YEAR) MAR indicated [REDACTED]. On 08/29/18 at 11:35 AM, the surveyor made the Director of Nursing (DON), the Assistant Director of Nursing, and the Administrator aware of the above findings. The DON stated that the narcotic Klonopin should not have been stored in the top drawer of the medication cart and should have been administered to the resident immediately after dispensing. A review of the facility's Medication Administration Policy and Procedure dated 5/1/11 indicated, .Document the following as applicable: Administration of the medication on the MAR indicated [REDACTED].Assure controlled substances are double locked. NJAC 8:39-29.2(d),29.6(c)

Based on observation, interview and record review, it was determined the facility failed to implement an established care plan to ensure the resident had 1:1 supervision to minimize falls and injury. This deficient practice was identified for Resident #7, 1 of 18 residents reviewed for comprehensive care plans as evidenced by the following: 1. During the initial tour on 5/11/15 at 10:55 a.m., the surveyor observed Resident #7 in the dayroom seated in a wheelchair with a left lower extremity pressure relief boot on. The Unit Manager (UM) who accompanied the surveyor during the tour, stated that Resident #7 had a history of [REDACTED]. Review of the resident's ongoing care plan initiated on 9/23/14, identified Resident #7 at risk for falls and injury related to unfamiliar surroundings, [DIAGNOSES REDACTED]. Resident #7 had a fall on 10/15/14 and sustained a skin tear to his/her outer wrist. Review of the fall investigation dated 12/4/14, revealed that Resident #7 sustained a fall on 12/4/14, resulting in a fracture to his/her right hip. The investigation concluded that the resident was attempting to put on pajama bottoms, slipped and fell . According to hospital records, the resident had right hip surgery to repair the fracture and returned to the facility on [DATE]. Subsequent fall investigations revealed Resident #7 fell again, the night of 12/11/14, the day he/she returned after surgical repair from the 12/4/14 fall. The other falls included: 12/15/14, 12/22/14, 12/23/14, 12/29/14, 1/3/15, 1/4/15, 1/8/15 and then again on 1/11/15. On 1/8/15 after a fall, the care plan was revised for the resident to be placed on 1:1 observation as necessary. On 1/11/15, the resident sustained [REDACTED]. According to the investigation, A facility nurse heard someone yell help and saw the resident lying on the floor in the hallway, the resident complained of left pelvic pain and 911 was called. The investigation revealed the resident was observed sitting in his/her wheelchair in the day room prior to the fall. According to hospital records, the resident had left hip surgery to repair the fracture and returned to the facility on [DATE]. NJAC 8:39-11.2(e)2

Based on observation, interview and review of medical records, it was determined that the facility failed to implement timely interventions to keep a resident, known to have poor safety awareness and impulsiveness, safe from fractures. Two falls, 5 weeks apart, resulted in 2 fractures requiring hospitalization s and surgeries. This deficient practice occurred for Resident #7, 1 of 8 residents reviewed for falls. The Facility also failed to maintain a safe environment. The evidence was as follows: 1. Resident #7 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Upon admission, the resident was independent with mobility and toileting. The Surveyor and the Unit Manager (UM) observed Resident #7 on 5/11/15 at 10:55 a.m. The resident was seated in a wheelchair in the dayroom at an activity. The Surveyor was told by the UM that Resident #7 removes safety alarms and, has falls that result in injuries. The Surveyor interviewed the UM again on 5/14/15 at 9:50 a.m. The UM told the surveyor that Resident #7 had many falls and hip fractures. A review of the Care Plan for Resident #7, initiated upon admission, identified the resident at high risk for falls and injury. The care plan indicated the resident was full weight bearing and able to independently walk upon admission. Resident #7 was also identified as being unfamiliar with his/her new surroundings, having poor safety awareness, dementia and confusion. On 5/14/15 at approximately 10 a.m., the Surveyor reviewed the facility documentation regarding falls after Resident #7's admission on 9/18/14. The first fall was less than 1 month after admission on 10/15/14 at 10:45 p.m. The incident was unwitnessed and occurred in the bathroom. Resident #7 sustained a skin tear to the wrist. The investigation indicated the safety device was an alarm on the bed. It did not indicate if the alarm sounded. A facility nurse wrote a statement indicating Resident #7 ' s roommate alerted staff to the fall. A second unwitnessed fall occurred on 12/4/14 at 7:45 p.m. in Resident #7 ' s room. This resulted in a Right hip fracture and hospitalization . The facility 's Investigation Summary indicated that staff heard, help which prompted them to enter the room. The Investigative Summary restated the problems previously identified on the Care Plan as poor safety awareness and confusion. It stated further, safety interventions to be implemented upon resident 's return from the hospital. Resident #7 returned to the facility on [DATE] after surgery for [REDACTED].#7 returned from the hospital, another unwitnessed fall occurred. At 9:30 p.m., Resident #7 was observed crawling on the floor. An unsigned statement attached to the investigation concluded the fall happened due to post-surgical confusion. Another unwitnessed fall, occurred 3 days later on 12/15/14 at 7:40 a.m., in Resident #7 ' s room. The resident stated afterward to staff he/she needed to go outside as there were children playing there. Four days later on 12/19/15 at 6:45 a.m., an unwitnessed injury was noted. Resident #7 was found to have a 2.5 centimeter laceration with dried blood and a bruise to his/her jaw. The investigated indicated how, why and where it happened were unknown. On 12/22/14 at 5:30 a.m., Resident #7 had an unwitnessed fall when he/she removed the alarm from the wheelchair and was found in the hallway. Resident #7 fell again 2 days later on 12/23/14, at about the same time of day, 5:40 a.m., in the facility 's dayroom seated not in the wheelchair but in a dining room chair. Resident was heard to say, get me up, I want to go to sleep. A statement attached to this investigation indicated there were no witnesses to this fall. Resident #7 fell again, 6 days later on 12/29/14 at 9:45 p.m. The investigation indicated the fall was unwitnessed by staff. The roommate stated he/she saw the resident attempt to self-transfer from the wheelchair to the bed. Another unwitnessed fall occurred 5 days later on 1/3/15 at 4:15 a.m. The facility 's Interdisciplinary Progress Note dated 1/3/15, indicated that one to one (1:1) safety intervention was in place at 1:30 a.m. prior to the fall as resident #7 was getting up and down. At 4:15 a.m., another resident 's alarm sounded and the staff member providing 1:1 left Resident #7 to go to that room. When the staff member returned to Resident #7, he/she was sitting on the floor in the hallway moaning in pain although no injury was apparent. The next day on 1/4/15 at 5:00 a.m., an unwitnessed fall occurred in Resident #7 's room. The conclusion of the investigation was the resident slid off the mattress onto the floor. Four days later, on 1/8/15 at 8:35p.m., a witnessed fall occurred in the dayroom. Resident #7 stood up from his/her wheelchair to help a resident that had trouble with their oxygen tubing and fell . No apparent injury occurred at that time. Another unwitnessed fall occurred on 1/11/15 at 11:15 a.m., in the hallway. This was the tenth fall where Resident #7, who was known to be impulsive, confused and prone to falls was not directly supervised by staff, and did not have adequate safety measures in place. This fall resulted in a second hip fracture since admission less than 3 months earlier. This fall also resulted in pain, surgery and hospitalization . The investigation indicated that a nurse heard, help and turned and saw Resident #7 on the floor in the hallway moaning in pain. Reiterated on the facility 's Investigation Summary was that Resident #7 had poor safety awareness and impulsiveness. It stated further, Apparently (the resident) removed the seatbelt and stood up to ambulate. The surveyor reviewed the current Care Plan for Resident #7. The Care Plan revealed that Resident #7 requires staff assistance for transferring from surface to surface. Resident #7 is also dependent on staff for dressing and toileting. The resident can no longer feed herself and needs assistance by staff. 2. At 10:45 a.m., the surveyor observed that there was a light switch cover missing at the entrance door in the physical therapy room with exposed wiring connections that were energized. The surveyor observed that there were residents and staff utilizing the room for therapy and posed a risk of electrical shock. Room is utilized only when staff present and kept locked. NJAC 8:39-27.1(a) NJAC 8:39-31.2(e)

Complaint #: NJ Refer to F 224Based on interviews and review of the medical records (MR) and other facility documentation, it was determined that the facility failed to ensure that the Interdisciplinary Resident Care Plan (RCP) was updated/revised in a timely manner with interventions to protect 1 of 2 cognitively impaired residents sampled (Resident #2) from inappropriate interactions/behaviors by Resident #1. The inappropriate interactions/behaviors included Resident #1 asking to go to bed with Resident #2. Resident #1 massaged Resident #2's neck, rubbed Resident #2's thigh, Resident #1 was found "repeatedly" in the unit shower room with Resident #2 and Resident #1 was found in Resident #2's bed. The day after Resident #1 was found in Resident #2's bed, Resident #1 was observed by a Recreation Aide (RA) standing over Resident #2, who was sitting on a chair in the bathroom (BR) with his pants unzipped and "exposed." Resident #1 was "getting ready to touch" Resident #2 inappropriately "but stopped" when the RA entered the BR. The RCP for Resident #1 was not revised with interventions until 9/12/2014, the day after Resident #1 was sexually inappropriate with Resident #2. This deficient practice of failing to implement/revise interventions on the RCP resulted in an Immediate Jeopardy (IJ) situation for Resident #2. The facility Administrator and Director of Nursing were made aware of the Immediate Jeopardy which began on 9/10/2014 and was identified on 9/19/2014 at 3:50 p.m. and was corrected on 9/19/2014 at 5:20 p.m. when an acceptable plan of correction was implemented. This deficient practice is evidenced by the following; Observations, interviews with staff and residents, review of the MRs and other facility documentation occurred on the day of survey, 9/19/2014, unless otherwise indicated. 1. See example #1 The Immediate Jeopardy was lifted on 10/19/2014 based on the plan of correction submitted on the same day at 5:20 p.m. by the Administrator which included the following; 1. Resident #1 was placed on 1:1 staff monitoring.2. All residents have the potential to be affected.3. Resident #1 will be reevaluated weekly. 4. All incidents will be reviewed by the Interdisciplinary Team (IDT) daily in the morning meeting.5. In-services began on acceptable wandering practices which included that residents should not be permitted to go into other resident's room unsupervised or not be in another resident's room, bathroom or closed area such as a shower room.6. In-services began and are ongoing, on signing the monitoring sheet and responsibilities of the monitor.7. Resident #1's RCP was updated and in-services began and are ongoing on the updating of the RCP appropriately and timely.8. In-services began and are ongoing, on Resident Rights of Privacy and what to report as an incident.9. The DON will monitor the systemic change to ensure the safety of residents and the Quality Assurance Committee will meet and monitor the effectiveness and outcome.NJAC: 8:39-27.1 (b)

C# NJ , C# NJ and C# NJ Based on interviews and review of medical records and other pertinent facility documentation, it was determined that the facility staff failed to promptly report incidents of suspected resident abuse to facility management. Therefore, preventing the initiation of action(s) as required by the facility's own policy, "Reporting Abuse to Facility Management" in order to ensure resident safety. This resulted in an immediate jeopardy situation for 3 of 5 sampled residents (Resident #2, #3 and #4). The immediate jeopardy was identified on 3/4/13 at 6:00 PM and corrected on 3/4/13 at 11:15 PM based on an acceptable plan of correction (POC) received from the Administrator which has been implemented by the facility. This deficient practice was evidenced by the following; 1. A review of a facility Reportable Event Record/Report dated 2/28/13 indicated that on 2/21/13 on the 3-11 shift Certified Nursing Aide (CNA) #3 witnessed CNA #1 screaming at Resident #2, "look at this A------ He's disgusting. Look what alcohol did to him." However, CNA #3 had not reported the verbal abuse she had witnessed until 10:50 PM on 2/26/13 (5 days later), therefore allowing CNA #1 to continue providing resident care on the 3-11 shift on 2/22/13 and 2/26/13. According to the Minimum Data Set (MDS), an assessment tool, dated 2/22/13, Resident #2 was cognitively impaired with long and short term memory problems, required the assistance of 2 caregivers for transfers, required the assistance of one caregiver for eating and hygiene and was non-ambulatory. [DIAGNOSES REDACTED]. During an interview with the surveyor on 3/4/13 at 7:00 PM, CNA #3 stated that she was aware of the facility policy on reporting abuse and should have reported the verbal abuse that she witnessed on 2/21/13 but she was afraid of CNA #1. However, when she had witnessed CNA #1 physically and verbally abuse Resident #3 on 2/26/13, she knew she had to report both incidents and did so on 3-11 shift of 2/26/13. 2. A review of a facility Reportable Event Record/Report dated 2/28/13 indicated that on 2/26/13 on the 3-11 shift, CNA #3 witnessed CNA #1 grab the back of Resident #3's sweatshirt with both hands. CNA #1 then took her knees and pushed the back of the resident's legs causing Resident #3 to fall to the floor on both knees. At the same time, "in a louder voice than normal tone and very agitated" CNA #1 stated to Resident #3 " You F------ A------" this incident was reported to a 3-11 shift nurse and to the evening supervisor. The resident had red knees when checked by CNA #3 about 20 minutes after the incident. According to the MDS dated [DATE], Resident #3 was cognitively impaired with long and short term memory problems, required the assistance of 1 caregiver for transfers, ambulation in the corridor, dressing, eating and hygiene. [DIAGNOSES REDACTED]. During an interview with the surveyor on 3/4/13 at 7:00 PM, CNA #3 stated that she had witnessed CNA #1 verbally and physically abuse Resident #3 on 2/26/13 at approximately 10:15 pm. CNA #3 witnessed Resident #3 holding onto the door frame of the bathroom and had resisted going into the bathroom. Therefore, CNA #1 grabbed the back of the resident's sweatshirt, then took her knees and pushed the back of the resident's legs causing him to fall on his knees. The resident shouted "ouch" and started to shake. The resident was picked up from the floor, evening care was rendered and Resident #3 was put to bed, by CNA #2 and #3. CNA #3 continued to finish her assignment as well as CNA #1. At approximately 10:50 AM, 35 minutes after the witnessed verbal and physical abuse, CNA #1 was preparing to clock out for the 3-11 shift, it was at that time that CNA #3 reported the witnessed verbal and physical abuse of Resident #3 by CNA #1 to the 3-11 RN supervisor and also informed the 3-11 RN evening supervisor that the resident's knees were red. When CNA #3 completed the interview with the 3-11 RN supervisor the 3-11 shift was over and CNA #1 had already left the facility. Furthermore, CNA #3 stated that she had not called the nurse to the room immediately in order to assess Resident #3 for injuries after the fall and did not immediately report the verbal and physical abuse of Resident #3. During an interview with the surveyor on 3/4/13 at 9:30 PM, the 3-11 shift RN supervisor stated that CNA #3 reported on 2/26/13 at 10:50 PM that she witnessed CNA #1 verbally and physically abuse Resident #3 at 10:15 PM (approximately 35 minutes later). At the same time, CNA #3 reported that she had witnessed CNA #1 verbally abuse Resident #2 on 2/21/13 (5 days ago). When the RN supervisor had completed the interview with CNA #3, she had immediately notified the Director of Nursing (DON) of the allegation and informed the DON that CNA #1 had already clocked out and left the facility. A review of facility documents revealed that CNA #1 was suspended on 2/27/13, 6 days after the alleged verbal abuse to Resident #2 and 1 day after the alleged physical and verbal abuse to Resident #3. 3. A review of the facility Reportable Event Record/ Report dated 2/22/13 indicated that on 2/12/13 at approximately 6:00 PM, CNA #2 allegedly had cursed a nurse in the room of and in the of presence of Resident #4 . CNA #3 and a Registered Nurse who had witnessed the event on 2/22/13 had not reported the incident until 2/12/13, 9 days later, therefore allowing CNA #2 to continue to provide resident care on the 3-11 shift on 2/13/13, 2/14/13, 2/16/13, 2/17/13, 2/19/13 and 2/29/13. According to the MDS, dated [DATE], Resident #4 was cognitively impaired with long and short term memory problems, required the assistance of 2 caregivers for transfers, required the assistance of 1 caregiver for dressing and hygiene, and was incontinent of bowel and bladder. [DIAGNOSES REDACTED]. During an interview with the surveyor on 3/4/13 at 7:00 PM, CNA #3 stated that on 2/12/13 around 6:00 PM, she heard CNA #2 cursing inside the room of Resident #4 "that F------ Nurse." When CNA #3 entered the room Resident #4 was awake in bed and CNA #2 continued to yell "that B---- don't know who she is messing with." CNA #2 was referring to the 3-11 shift RN. CNA #2 "was mad the whole time" and popped the resident's Mylar birthday balloon. CNA #3 tried to calm CNA #2 in the resident's room. CNA #3 informed the surveyor that she was aware of the facility policy on reporting abuse, however did not report the incident because she assumed that the 3-11 shift RN who had also witnessed the incident, and who CNA #2 was cursing, would have reported it. CNA #3 reported the incident on 2/21/13 (9 days later) when the DON questioned her about an incident involving CNA #2 and the 3-11 shift RN on 2/12/13. During an interview the surveyor on 3/6/13 at 3:30 PM, the DON stated that on 2/21/13, during an interview with the 3-11 shift RN regarding her resignation, is when she became aware of an alleged abuse incident that took place on 2/12/13. CNA #2 was cursing in the room of Resident #4. CNA #2 was yelling "That F------ nurse, look at this" and continued ranting in front of the resident "This really pisses me off", CNA #2 was so angry that "she grabbed the resident's birthday balloon and popped it." The 3-11 shift RN informed the DON that CNA #3 witnessed the incident. The RN was questioned on why she waited to report, the RN stated that she was aware of the reporting policy and procedures of the facility but feared CNA #3, therefore the RN decided to resign. Furthermore, the 3-11 shift RN refused to write a statement or be contacted by anyone further to discuss the incident, and wanted to resign effective immediately. CNA #3 was immediately interviewed by the DON on 2/21/13. CNA #3 reported that on 2/21/13 she heard CNA #2 yelling from the room of Resident #4. CNA #3 entered the resident's room and CNA #2 continued to yell " that F------ B---- came in here and covered up this lady." The resident was covered in feces. CNA #3 was also questioned on why she waited to report, CNA #3 stated that she was aware of the reporting policy and procedures of the facility however was afraid of CNA #3. The DON added that she had immediately re-assigned CNA #2 to the Dietary Department. During an interview with the surveyor on 3/6/13 at 2:00 PM, CNA #2 stated that she was upset and angry that someone had left Resident #4 with feces all over her. However, had not cursed in front of the resident but in the hallway "What B---- left this for me". CNA #2 admitted , that with her pen, had popped the Mylar birthday balloon that belonged to Resident #4. The balloon was deflating and it was getting in her way while she was rendering care to Resident #4. CNA #2 added that she had not informed and/or received consent from the resident of her intended action. A review of the facility policy titled "Reporting Abuse to Facility Management" not dated, indicated "It is the responsibility of our employees, facility consultants, attending physicians, family members, visitors etc. to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of an unknown source, and theft or misappropriation of resident property to facility management. NJAC 8:39-4.1(a)5 The Immediate Jeopardy was lifted on 3/4/13 at 11:15 PM, based on an acceptable POC submitted by the Administrator which included the following; 1. CNA #1 was immediately suspended on 2/27/13 upon being made aware of the allegation. CNA #2 was transferred to the Dietary Department on 2/22/13. Department of Health contacted on 2/22/13 and 2/27/13. Ombudsman's office contacted on 2/22/13 and 2/27/13. Wall Police contacted on 2/27/13. Immediate re-education of all staff on reporting procedures started 3/1/13. The CNA (CNA #3) who failed to report the incident initially was re-educated on a 1:1 basis on 2/28/13 and stressed zero tolerance for resident abuse. 2. Will review weekly body checks for those residents on alleged employee's assignment for CNA #1and #2 for February 2013. Resident #3 body assessment completed on 2/27/13 by the 11-7 Nursing Supervisor. Resident #4 body assessment completed by the nurse on 2/12/13. Alert and oriented residents will in interviewed. Affected residents assessed as stated above. 3. Posting of notices in employee areas on March 4, 2013 i. e. bathrooms, breakroom, employee education boards, time clock, enforcing zero tolerance for abuse and failure to report immediately starting 3/4/13. Random/unannounced nurse supervisors/administration to work 3-11 shift for increased supervision a minimum of one time a week starting March 4, 2013. Responsibilities to include interviewing a resident, staff and checking employee assignments.. Will research setting up "Hotline" for abuse reporting in the event employees are fearful of reporting. Message to potentially include:Brief description of incident, time and potential witnesses. Started research 3/4/13. Supervisor who failed to do body check was verbally disciplined, re-educated/re-inserviced on 3/4/13. Other disciplinary actions will be ongoing. 4. Continued re-education of all employees stressing zero tolerance for abuse and reporting procedures to be conducted twice a year and as needed. Completed 3/4/13 and ongoing.

Based on interview, record review and review of the facility policies, it was determined that the facility failed to initially report, investigate and follow up on all injuries and incidents as required for 2 residents, Resident #11 and #19. Resident #11 had an incident on 2/9/12 at 8 p.m. while being transferred from her wheelchair to her bed. This incident was not reported and only revealed after Resident #11 was hospitalized with injuries on 2/11/12. Resident #19 was noted to have a bruise on the outside of her right eye and nose on 11/15/11 that was not investigated. This deficient practice was observed for 2, Residents #11 and #19, of 20 residents reviewed and was evidenced by the following: 1. Resident #11 was admitted [DATE] and had [DIAGNOSES REDACTED]. According to the resident ' s Minimum Data Set (MDS) assessment tool of 1/8/12, the resident was cognitively impaired and required a total assist of 2 staff members for transfers. On 2/11/12, according to the Interdisciplinary Progress Notes (IPN), the resident complained of pain in her left leg in the a.m. (no time given), and was given medication. The next documentation in the IPN was on 2/11/12 at 10:30 a.m. which indicates that the resident was out of bed to a wheelchair and had complained of pain earlier in the shift. The next documented complaint of pain was 2/11/12 at 11 p.m., when the resident again complained of pain in her left leg. According to documentation in the IPN the left leg was reddened and hot to touch with plus 2 [MEDICAL CONDITION], pedal pulses were present. Resident #11 complained of severe pain to the left hip and groin area upon movement of the leg. The physician was notified and the resident was sent to the hospital for evaluation. The resident was found to have a [MEDICAL CONDITION] plateau of the left proximal tibia and was admitted . After the fracture was diagnosed , the facility initiated an investigation. It was at that time that the facility was made aware of the unreported incident of 2/9/12 and got statements from the 2 involved Certified Nursing Assistants (CNA). According to the CNA statements, dated 2/16/12, they explained that on 2/9/12 at approximately 8-8:30 p.m. when transferring Resident #11, she said, "ow" and CNA #2 said, "her leg is stuck." According to CNA #2's statement, they lifted her leg up and then put her to bed. The CNAs noted that Resident #11 had a slight indentation above her knee. The surveyor interviewed CNA #1 on 2/29/12 at 1 p.m. CNA #1 demonstrated how she moved the resident and indicated that the residents leg got caught between the mattress and the siderail. On 2/29/12 at 9:15 a.m., the surveyor discussed the lack of an investigation with the facility Administration. According to the Administrator and the Director of Nursing that after speaking with the CNA's concerning the incident on 2/9/12 at approximately 8-8:30 p.m., they learned that both CNAs said that they thought the other had reported the incident to the nurse. The surveyor reviewed the facility's Accidents and Incidents - Investigating and Reporting Policy on 2/29/11. Section 1, (a) notes that "Regardless of how minor an accident or incident may be, including injuries of an unknown source, it must be reported to the department supervisor as soon as such accident/incident is discovered or when information of such accident/incident is learned." Section 1 (d) of the same policy notes "the nurse supervisor/charge nurse must be immediately informed of accident or incidents so that medical attention can be provided." This was not done. Refer to F323 2. Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the MDS dated [DATE], indicated that the resident had long and short-term memory problems. This same MDS revealed that the resident required assistance from staff for Activities of Daily Living (ADL's), and for transferring from the bed to the chair. Review of the IPN dated 11/15/11 at 10 a.m. revealed that during a body check a nurse identified that the resident had a 1.5 centimeter (cm) by 1 cm ecchymotic (a discoloration of the skin) area on the outside of her right eye and nose. According to the IPN note dated 11/18/11 at 7 a.m. and noon, the resident's bruise remained visible. During an interview conducted on 2/28/11 at 2:00 p.m., the Administrator, the Director of Nursing (DON), and the Risk Manager stated that all injuries and bruises were investigated. The DON stated that it was the Risk Manager's responsibility to follow up on all investigations. When interviewed on 2/29/12 at noon, the Risk Manager stated that there was no investigative report available to explain how the bruises may have occurred. The Risk Manager added that she was not aware of the resident's bruise and staff did not report the bruise as required by the facility policy and as a result an investigation was never started. The facility failed to follow their policy concerning Resident #19's injury. NJAC 8:39-4.1(a)5, 27.1(a)

Based on interview and record review it was determined that the facility failed to transfer a resident utilizing the appropriate assessed number of staff members for assistance. Consequently, one resident, Resident # 11, sustained a fractured tibia, severe pain and was hospitalized for [REDACTED]. Resident #11, an [AGE] year old resident, had [DIAGNOSES REDACTED]. During a tour of Unit C on 2/23/12 at 10 a.m. with the Charge Nurse, the surveyor observed Resident #11 seated in a geri-recliner. The nurse stated that the resident was confused, non ambulatory and the previous week developed severe pain in the leg and hip area, was sent to the hospital and found to have a fracture of the tibia. The nurse stated the resident had not fallen. According to the Minimum Data Set (MDS) an assessment tool, dated 1/8/12, the resident was totally dependant on two staff members for transfers from the wheelchair to the bed. The surveyor reviewed the resident's most recent Care Plan dated 10/18/11. The Care Plan included the care instructions that the staff must pivot Resident #11 for transfer with the assist of two staff members. Resident #11 was referred to Physical Therapy because it was reported that she was having increased difficulty transferring even with a 2 person assist. The Initial Rehabilitation assessment dated [DATE] noted the reason for the referral and indicated that Skilled Therapy was advised. The surveyor reviewed the Interdisciplinary Progress Notes (IDP) which documented that on 2/11/12 at 11 p.m. the resident complained of severe pain in the left leg and groin upon movement. The left leg was noted to be reddened, hot to touch with plus 2 edema. The physician was called and the resident was sent to the hospital for an evaluation. Resident #11 was diagnosed to have a Lateral non displaced tibial fracture and was admitted . Resident # 11, according to the MDS, required the extensive assist of 2 staff for all transfers. CNA #2's written statement provided by the facility indicated that on 2/9/12 at approximately 8 p.m. CNA #2 called CNA #1 to assist her in transferring the resident from the wheelchair to the bed. CNA #2 placed the resident's wheelchair next to the bed. CNA #1, said, "step back I got it " and she lifted the resident up to put her in the bed. The resident said "ow" and CNA #2 told CNA #1 that the resident's leg was caught on the bed. They assisted the resident to free her leg and sat her on the side of the bed. A slight indentation above the knee was noted on the resident. The skin was intact and there was no redness On 2/29/12 at 1:00 p.m. the surveyor interviewed CNA # 1. CNA #1 confirmed that the resident's leg got caught in the gap between the mattress and the siderail during the transfer from the wheelchair to the bed on 2/9/12. CNA #1 stated and demonstrated how she helped the resident by holding her under the arms to transfer her when told the resident's leg was caught in the siderail. CNA #1 said that while she was holding the resident under the arms, CNA #2 helped to get the resident's leg out of the siderail. The surveyor interviewed the Director of Nursing and the Administrator on 2/29/12 at 9:15 a.m. They stated that their investigation of the 2/9/12 incident revealed that the resident's leg was hit and/or stuck in the siderail. The CNAs received additional education on transferring residents and disciplinary action was pending because the resident was directed to be a 2 person transfer. Refer to F226 NJAC 8:39-27.1 (a)

Based on observation, staff interviews and record review, it was determined that the facility failed to revise care plan interventions for 4 of 24 sampled residents. Specifically for Resident #2 and Resident #18 who were at risk for constipation; and Resident #4 and Resident #6 who were at risk for accident and injury. Resident #2 developed fecal impactions resulting in 2 hospitalization s and Resident #6 had a fall which resulted in a fracture. The deficient practice was evidenced by the following: 1. Resident #2 was receiving [MEDICATION NAME], an [MEDICATION NAME] medication, 3 times daily for pain. A review of the Interdisciplinary Progress Notes documented that Resident #2 had been complaining of gastrointestinal (GI) discomfort from 3/1/11 to 3/24/11. Further record review indicated that Resident #2 was hospitalized from [DATE] to 4/1/11 and diagnosed with [REDACTED]. On 4/8/11 the surveyor reviewed Resident #2's Care Plan. There was no intervention in place that addressed constipation/ fecal impaction. On 4/8/11 the surveyor interviewed the Dietitian (RD) who stated that she was never informed of Resident #2's constipation issue. There was no documentation that extra fluid consumption was encouraged , no meal monitoring form and no dietary alert was available for review. When the resident returned to the facility on [DATE], the RD was not aware of the [DIAGNOSES REDACTED]. On 4/11/11 the surveyor again reviewed Resident #2's medical record. There was no Care Plan in place to address the fecal impaction and prevent recurrence. There was no Interdisciplinary meeting yet to address the fecal impaction and measures to prevent this high risk resident from the development of another fecal impaction. ( Refer to F-309.) 2. Resident #4 had 5 falls at the facility from 1/16/11 to 2/28/11. The resident Care Plan initiated 10/17/10 did not include meaningful interventions to prevent further accidents from occurring. There was no revision made to the Care Plan in the presence of all these falls. (Refer to F323.) 3. Resident #6 was admitted to the facility on [DATE] after a hospitalization for a fall at home that led to a fractured femur. The Care Plan reflected interventions for falls from the bed and an alarm to the wheelchair. However, despite ongoing documentation indicating that the resident also attempted to rise from the wheelchair and walk unassisted, no interventions were added to keep her safe from falls while in the wheelchair. Consequently, Resident #6 stood up while in the dayroom, fell and suffered a [MEDICAL CONDITION]. (Refer to F323.) 4. The surveyor reviewed the medical record of Resident #18 on 4/12/11. The resident was admitted to the facility on [DATE]. According to the 4/11 MAR indicated constipation" on 4/2 and 4/3. Two attempts were made to administer MOM to the resident on 4/10 due to constipation and MOM was administered on 4/11. A review of the Bowel Record for Resident #18 revealed that from 4/4 thru 4/11 the resident only had 2 "small" bowel movements on 4/7. The surveyor reviewed Resident #18's care plan on 4/12. The resident did not have a care plan for constipation. The surveyor interviewed the Registered Dietician (RD) on 4/11 at 11:30 a.m. The RD stated that she was unaware that the resident had constipation. She further stated that had she been aware, a care plan would have been developed to include dietary interventions i.e. prune juice, a dietary fiber mixture and extra fluids on the resident's meal tray. (Refer to F309.) NJAC 8:39-11.2(e)(h)(i)

Based on observation, interviews and record review, it was determined that the facility failed to provide care to residents with signs and symptoms of constipation, burning and pain and rapid weight gain. Subsequently, Resident #2 developed recurrent impaction which required hospitalization . This deficient practice was identified for Residents #1, #2, #8, and #18, 4 of 21 residents reviewed for quality of care. Evidence was as follows: 1. During the initial tour on 4/7/11, the surveyor observed Resident #2 in bed. The nurse who toured the unit with the surveyor stated Resident #2 was confused, had a weight loss and was being treated for [REDACTED]. The surveyor reviewed the resident's medical record on 4/8/11 which indicated Resident #2 had a [DIAGNOSES REDACTED]. The Minimum Data Set(MDS) assessment tool dated 1/8/11 reflects that the resident is totally staff dependant for care and is incontinent of bowel and bladder. The surveyor reviewed the March 2011 physician's orders [REDACTED]. During a 4/8/11 interview with the the CNA usually assigned to the resident the CNA confirmed that Resident #2 required total care. The CNA further stated that Resident #2 was recently hospitalized for [REDACTED]. On 4/8/11 the surveyor reviewed Resident #2's bowel summary data from October to February. According to the data provided in these summaries, Resident #2's bowel habits were very regular and he was noted as having a bowel movement almost every shift. On 4/8/11 the surveyor reviewed the interdisciplinary notes from 3/1/11 to 3/24/11. The nurses notes dated 3/1/11 documented "Resident c/o (complained of ) stomach ache; noted to be distended abdomen, soft bowel sounds in all 4 quadrants - refused to take Milk of Magnesia (MOM); received order for [MEDICATION NAME] suppository 1 rectally now. Stool in rectum noted." There was no documentation in the nursing notes nor on the back of the Medication Administration Record (MAR) to indicate if the laxatives were effective. The next nurses note's dated 3/4/11 8:00 p.m., documented " Resident vomited brown fluid x 3 ... abdomen soft, distended bowel sounds in all 4 quadrants. Dr ... called; new order for [MEDICATION NAME] suppository 1 time dose." The effectiveness of the medication was again not documented. On 3/7/11 the nurses note documented "up at times mumbling and yelling." There was no documentation to indicate that the constipation had resolved or continued. Another nurse's note dated 3/17/11 at 8:30 p.m. documented " spoke to Dr ... concerning constipation and increased use of MOM. Order received to increase Senna to 2 tab daily." Another entry at 9:30 p.m. documented " spoke to Dr .... Concerning constipation, abdomen distended with low pitch bowel sounds. New order received for [MEDICATION NAME] suppository..." There was no documentation in the nurse's notes or in the back of the MAR to indicate the result of the medication administered. On 3/22/11 the nurse's notes documented, " Milk of Magnesia given x 2 ; no bowel movement, received order to administer Fleet Enema. Fleet Enema x 1 now given with good result." The surveyor reviewed the bowel summary for that day which indicated that the laxative was given and there was no bowel movement. On 4/8/11 at 2:20 p.m. the surveyor interviewed the Certified Nursing Assistant (CNA) who routinely cared for the resident. The CNA stated that Resident #2 was combative with the procedure and that the enema was not successfully administered on 3/22/11. The next entry regarding Resident #2's constipation was on 3/24/10 at 6:15 p.m., which documented " Vomited x2 large amount of dark brownish black fluid, alert, verbally responsive yelling at staff ....transferred to hospital for evaluation, ....admitted with GI ([MEDICAL CONDITION])." On 4/8/11 the surveyor reviewed Resident #2's hospitalization record and noted the following in the Physician's Progress Record dated 3/25/11: " Resident agitated and confused, abdomen markedly distended, is tympanic high pitch bowel sounds. [MEDICAL CONDITION] tube was inserted and occult blood for [MEDICAL CONDITION] content was negative; impacted stool was manually removed in the emergency room ." Further review of the Physician's Progress Record revealed that Resident #2's admission [DIAGNOSES REDACTED]." An abdominal X ray performed at the hospital on [DATE] revealed both the large and small bowel were dilated with moderate amount of fecal material noted in the colon. On 4/8/11, the surveyor reviewed the CNA's documentation of the resident's bowel summary which indicated that Resident #2 did not have bowel movements for 11 shifts between 3/14/11 and 3/17/11. The integrated nursing progress notes dated 3/13/11 through 3/17/11 did not document the resident's bowel movement nor did it document that the physician was made aware of the laxative results. The bowel summary dated 3/24/11 documented Resident #2 had a good bowel movement on the evening shift. Resident #2 was transferred to the hospital at 6:15 p.m. on 3/24/11 and had to be manually disimpacted in the emergency room . On 4/8/11 the surveyor interviewed the Unit Manager (UN) regarding the facility bowel protocol. The UN referred the surveyor to the Nurse educator who stated that the facility did not have a bowel protocol at this time. However, the Nurse Educator relayed the bowel protocol was on the Quality Assurance's agenda for 2011. On 4/11/11 at 8:35 a.m. the surveyor interviewed the Registered Dietitian (RD) regarding Resident #2's issue with constipation. The RD told the surveyor that she was never made aware of Resident #2's constipation concerns. The dietitian stated "Had I known, I would add fluid to the diet and I would add a 'fiber cup' on his tray every morning." She further stated that she became aware of Resident #2 's fecal impaction only after she reviewed the medical record on 4/5/11. At that time the dietitian revealed she addressed Resident #2' s weight loss, and put interventions in place. Resident #2 returned to the facility on [DATE]. That same day the surveyor asked the dietitian what method the facility had in place to communicate interdisciplinary concerns. The RD indicated there was no system in place. The dietitian further stated she was usually verbally informed of nutritional issue/concerns. On 4/11/11 the surveyor interviewed the UM again requesting a dietary alert secondary to Resident #2's fecal impaction. The UM indicated there was none for review. The surveyor asked the UM for the meal monitoring form to verify Resident #2's intake for the month of March which the UM was unable to provide. The UM further stated that Resident #2's appetite fluctuated but could not be more specific regarding Resident #2's intake. There was no documentation in the nurse's notes regarding Resident #2's intake. The Physician order [REDACTED]. The Senna was increased to 2 tablets on 3/18/11. On 3/5/11 the physician ordered a [MEDICATION NAME] (laxative) 5 mg tablet every night for constipation. The resident also received 5 doses of Milk of Magnesia from 3/9 to 3/18/11. There was no documentation that extra fluid was provided to the resident when the resident began experiencing the constipation issues and the extra laxatives were ordered. On 4/8/11 the surveyor reviewed Resident #2's Care Plan initiated on 10/12/10 for altered diet consistency. There was no documentation regarding constipation nor were measures in place to address constipation. On the Care Plan evaluation for 10/12/10 the dietitian documented Resident #2's weight at 190.5 pounds and documented that his intake was good. The last entry on the Care Plan dated 4/5/11 documented a weight loss of 25 pounds and a [DIAGNOSES REDACTED]. There were no interventions for the constipation. The resident returned from the hospital on [DATE]. There was no nursing documentation, no meaningful interventions that addressed the fecal impaction, and no bowel program in place. An interview with the physician on 4/11/11 confirmed the [DIAGNOSES REDACTED]. The Physician further commented that he discussed the findings with the facility. Resident #2 returned to the facility on [DATE] with the [DIAGNOSES REDACTED]. On 4/8/11 when the surveyor reviewed Resident #2's medical record there was no intervention in place to address the fecal impaction. There was no Care Plan in place to address constipation. The facility did not implement a Care Plan nor put measures in place to prevent recurrence post hospitalization . Resident #2 was readmitted to the hospital with [REDACTED]. On 4/11/11 the facility was made aware of the concern with Resident #2, and was given the opportunity to provide more information for review. On 4/11/11 the facility provide some information for review, however there were discrepancies between the nurse's notes and the bowel summary book. For example, on 3/17/11 the nurse's notes documented Resident #2 had a bowel movement while the bowel summary book revealed a laxative was given and there was no bowel movement. The nurse's notes of 3/20/11 documented a Fleets enema was given with good result. An interview with the CNA who cared for the resident indicated that the resident was combative during the Fleet enema and the procedure was not successful. On 4/12/11 during a pre-exit conference, the facility was made aware of the survey team's concern regarding Resident #2 and asked the facility to provide additional information regarding Resident #2's fluid intake, any dietary alerts, meal consumption patterns, and any other interventions that were carried out to alleviate constipation. The DON stated the MAR and the nurses notes should have reflected what was given and the effectiveness of the interventions. On 4/13/11 at 11:30 a.m. during the pre-exit conference when further information was not provided, the DON stated " it is what it is." 2. Resident #8 was admitted to the facility on [DATE] and had the [DIAGNOSES REDACTED]. On 4/8/11 at 10:15 a.m., the surveyor observed Resident #8 seated in the dayroom with a staff member. The Resident had both hands between her legs and was pulling the incontinence brief forward and away from her body. Fifteen minutes later at 10:30 a.m., Resident #8 was observed propelling down the hallway, lifting her dress and using both hands to pull the brief away from the groin area on both sides. The resident was heard to say "Oh my God, it's killing me. It's burning. Oh, please hurry up." At this time, the Registered Nurse (RN), Unit Manager came down the hall and without stopping, asked Resident #8 "What's the matter (name)?" The Resident replied "I'm burning!" The RN, stated in passing by "I'll see if the nurse can give you medicine." At 10:35 a.m. the resident was again heard to repeat "It's burning." At 10:40 a.m. a nurse came to Resident #8 in the hallway and stated "Here's some Tylenol." Neither nurse assessed Resident #8 for the cause of her complaint of "burning" and the action of pulling the brief away from the skin. A review of the Medical Record for Resident #8 on 4/8/11 at 11:45 a.m. indicated that there was an order started on 3/24/11 which read "Baza cream to B/L (bi-lateral) groin twice daily x 7 days." The treatment ended 3/31/11. The April Treatment Administration Record also reviewed at this time indicated that there was no current treatment to the groin area. On 4/11/11 at 8:35 a.m. Resident #8 was lying in bed awake. The surveyor asked the resident if along with a CNA the surveyor could view her skin around the brief area. The resident said "yes." The CNA indicated that she already had done morning care and Resident #8 would soon be transferred to the wheelchair. Resident #8 had a pendulous abdomen and multiple folds in the groin area. While the CNA lifted all the folds to reveal underlying skin, the surveyor pointed out a small, oval shaped, ulceration in the fold of the inner left thigh. The CNA stated "Oh, I didn't see that." After surveyor intervention, a physician's orders [REDACTED]. A Record Review on 4/12/11 at approximately 2 p.m. indicated that the open area was not measured on 4/1/11 when discovered but referred to as "excoriation". Upon interview with a facility RN Supervisor at this same time, it was stated "it's an open area in the skin like a Stage 2 but it's not pressure related so we don't measure those." The facility failed to respond and assess the cause of Resident #8's indicators of pain and discomfort. Also, the facility failed to document an assessment of the ulceration, such as the underlying condition contributing to the ulceration, ulcer edges and wound bed, location, shape, condition of surrounding tissues to differentiate the ulcer type, since the ulcer had characteristics consistent with a pressure ulcer, but was determined not to be one. 3. The surveyor reviewed the medical record of Resident #19 on 4/12/11. The resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident had a physician order [REDACTED]. to be administered twice daily and MOM 30 cc every 24 hours as needed for constipation. According to a nurses note written on 4/2, the resident had not had a bowel movement for 3 days and MOM was administered. On 4/3/11 a nurses note was written which included that the resident had a "small BM/hard" and that the resident complained of "some difficulty" moving her bowels. MOM was again administered. On 4/4/11 the physician was notified that the resident was refusing to swallow the [MEDICATION NAME] and the order was changed to administer [MEDICATION NAME] liquid 200 mg. once daily. Two attempts were made to administer MOM to the resident on 4/10/11 which the resident refused. On 4/11/11 the MOM was successfully administered to the resident. A review of the Bowel Record revealed that from 4/5 thru 4/11/11 the resident had 2 "small" bowel movements on 4/7/11. The surveyor reviewed Resident #18's care plan which did not include constipation. The surveyor interviewed the Registered Dietician (RD) at 11:30 a.m. The RD stated that she was not aware that the resident had constipation. She further started that had she been notified of the constipation a care plan would have been developed to include dietary interventions i.e. prune juice, a dietary fruit/fiber mixture and extra fluids on the meal tray. The RD further stated that a recommendation also might have been made to the physician to order a "liquid fiber supplement." These interventions were not implemented for Resident #18 who had signs and symptoms of constipation. 4. During the initial tour on 4/7/11 at 9:30 a.m. the unit nurse told the surveyor that Resident #1 had a [DIAGNOSES REDACTED]. At 12:00 p.m. the surveyor observed the resident seated in a wheelchair in the room. The resident was using oxygen via a nasal cannula. On 4/8/11 the surveyor reviewed the medical record. The resident had a physician order [REDACTED]. On 1/4/11 the resident visited the Cardiologist who ordered to discontinue the resident's [MEDICATION NAME] (a diuretic) 40 mg. twice daily and wrote an order to administer the [MEDICATION NAME] 40 mg. once daily "only until weight increase by 2 lbs. (pounds) in 24 hours." A clarification of the order was written on 1/5/11 which read, "[MEDICATION NAME] 40 mg. daily - if resident gains 2 lbs. in 24 hrs. resume [MEDICATION NAME] 40 mg. BID (twice daily)." The surveyor reviewed Resident #1's MAR for 1/11, 2/11, 3/11 and 4/11. From 1/5 thru 4/8 the [MEDICATION NAME] was administered daily. Twice in March the resident had a greater than 2 lb. weight gain, from 3/5 - 3/6/11 a 3.2 lb. increase and from 3/18 - 3/19/11 a 2.8 lb. increase. A second dose of [MEDICATION NAME] was not administered to the resident at either time. On 4/11/11 at 1 p.m. the surveyor interviewed 2 different unit nurses regarding the [MEDICATION NAME] order. One of the nurses stated that the order meant that if the resident had a 2 lb. or greater weight gain then the [MEDICATION NAME] should be changed to be administered twice daily "indefinitely." The second nurse stated that the order meant that if the resident had a 2 lb. weight gain that the [MEDICATION NAME] should be administered a 2 nd time on that day only. The nurses who were responsible for medicating the resident were not clear on the physician order [REDACTED]. weight gain. N.J.A.C.8:39-27.1(a)

Based on interview and record review, it was determined that the facility failed to provide adequate interventions and supervision to prevent a resident identified at high risk for falls from experiencing a fall from a wheelchair with injury. As a result, Resident #6 fell in the dayroom and fractured her left hip requiring hospitalization and surgical repair. In addition the facility failed to implement new effective interventions to prevent Resident #4 from multiple falls out of bed. This deficient practice occurred for 2, Residents #4 and #6, of 9 residents reviewed for falls and was evidenced by the following: 1. Resident #6 was admitted to the facility on [DATE] after falling at home on 2/2/11 while ambulating independently. That fall resulted in hospitalization for a fractured tibia. Upon admission to the facility, Resident #6 had the additional [DIAGNOSES REDACTED]. During the initial tour on 4/7/2011 the surveyor observed Resident #6 who was in a chair with footrests, a pommel cushion and a seatbelt. According to an interview with the Registered Nurse, Unit Manager none of these interventions were put in place until 3/15/11 when Resident #6 was readmitted after a fall and fracture on 2/28/11. The facility's "Fall Risk Assessment" was done upon admission on 2/9/2011 and Resident #6 scored 22. According to the assessment tool a score greater than 10 indicated that the resident being evaluated was at "High Risk" for falling. Upon admission, the facility instituted a low bed, floor mats, encouraged proper footwear, monitored the resident as a fall risk secondary to medications, kept important belongings within reach, gave frequent reminders to rise slowly from lying to sitting position, and placed alarms to the bed and wheelchair. The 2/9/11 admission note timed 5:35 p.m. indicated that Resident #6 was continent of bowel and bladder, was partial weight bearing on the left leg and was noted with "increased anxiety." A nurses' note dated 2/10/11 and timed 3:30 p.m. indicated that Resident #6 was "out of bed in the wheelchair, anxious and restless." Further, the documentation reflected that the anti-anxiety medication Xanax was given at 4 p.m., and at 5:30 p.m. the Resident "remained anxious" and at 7 p.m. was found "climbing out of bed." A nurses' note dated 2/11/11- timed 6 a.m.- indicated "anxious at times, gait unsteady, receives PT (Physical Therapy) during the day." A Psychologist wrote on 2/11/11 that Resident #8 "forgets instructions, is memory impaired, has no insight into her problems." On 2/12/11, nursing documentation indicated that at 6 a.m. Resident #6 was "yelling, anxious, trying to climb out of bed." Later, at 9:50 a.m. Resident #6's wheelchair alarm was sounding and she was found on the floor. The facility investigation indicated that the resident stated "I tried to stand up to sit on the bed." No additional interventions regarding safety in the wheelchair were instituted. On 2/13/11 at 10:40 a.m. a nurse documented "MD (Medical Doctor) called, resident agitated, stood up from wheelchair. As needed Xanax increased to every 4 hours." On 2/14/11 at 4:45 a.m. a nurse documented "trying to get out of bed, anxious, attempts to redirect not effective, Xanax given." On 2/16/11 a psychiatric consultation was ordered due to Resident #6 being "anxious and agitated." The consult was completed on 2/25/11. The Xanax was discontinued and Depakote Sprinkles for mood disorder were increased from 250 mg twice a day to 375 mg twice a day. Resident #6 fell again on 2/22/11. At 7:10 a.m. Resident #6 was found on the floor in her room. A nurse's note reflected that the resident stated "I thought I could get back to bed alone, I'm so tired" and further "calling out help, getting out of chair unassisted." No care plan interventions were added regarding safety while in the wheelchair. A nurses note dated 2/23/11, timed 5 p.m., indicated "Resident continues to yell, trying to stand and take off (alarm) monitor." On 2/24/11, four days before the fall and fractured hip, a Physical Therapy Progress Note indicted that the Resident was ambulating with a rolling walker with contact guard supervision with partial weight bearing on the healing tibial fracture. The note further indicated that Resident #6's standing balance improved since admission but the resident was noted to be impulsive, a safety risk and required cues to stay on task and follow directions. On 2/25/11, timed 3 p.m., a nurse's note indicated "...continues to ambulate unassisted." On 2/27/11 at approximately 10 p.m. the resident was noted to have 1 to 1 care all evening as she was extremely agitated and restless. Throughout the night the resident wanted to go to bed and a short time later would attempt to get out of bed, screaming at staff. Pain medication and a tranquilizing agent were only minimally effective. A note timed 2:30 a.m. documented that the resident was screaming and threatening to throw herself on the floor if she was not gotten out of bed. The resident had been placed back in bed at her request just 40 minutes earlier. This pattern continued for several more hours. On 2/28/11 at 11:30 a.m. was seated in a wheelchair in the dayroom. Resident #6 stood up unassisted, fell and fractured her left hip. The nursing note timed 11:30 a.m. documents the following "heard alarm for w/c ringing and someone calling for help from the dayroom. Resident was on the floor on left side." The note further reveals that the resident was complaining of pain in the left leg. Neither the nursing notes nor the facility's event report reflect that Resident #6 was supervised at the time of the fall. Upon readmission on 3/15/11 after surgical repair of her hip, the facility provided a wheelchair with footrests, obtained orders for a pommel cushion to the wheelchair and a clip seatbelt. 2. Resident #4 had [DIAGNOSES REDACTED]. On 4/8/11 the surveyor reviewed Resident #4's record and noted that Resident #4 had falls on 1/16, 2/7, 2/17, 2/19, 2/25 and 2/28/11 with no injuries. The investigation report dated 1/16/11 indicated that the resident had a TABS alarm, bed pad alarm and floor pads in place. There is a statement taken on 2/7/11 from a CNA that Resident #4 was able to remove the TABS alarm and in fact did so three times during care on 2/7/11. The surveyor reviewed Resident #4's fall investigative reports with the Unit Manager. There was no documentation to indicate that interventions were reviewed and new interventions were put into place to prevent further falls. The surveyor reviewed the Care Plan initiated on 10/17/10 with the UM. There was no intervention in place to address the falls that took place while Resident #2 was in bed. The causative factors of the falls were not addressed. The Care Plan was not revised and no new interventions were added even after the 2/25/11 fall. Resident #4 was provided with a wedged bed after the fall of 2/28/11. During the pre-exit conference on 4/13/11, the DON indicated that the facility would work with the UM to develop a Care Plan based on the resident's needs. NJAC 8:39-27.1a